Developed by J. Moore and L. Swabey
CATIE, College of St. Catherine/NCIEC
DRAFT ~ 2007

This review of the literature related to medical interpreting was undertaken in 2007. You can view the entire report online, or can download the PDF of the report.

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Literature Review Contents

Sign language interpreters frequently provide services in medical settings. In fact, one agency reported that the majority of requests for services they receive are for medical interpreting (RID Views, 1999, p.13). Others estimate the rate of medical requests at 30-50% (Swabey, Alvarado-Little, & Taylor, 2006, p. 60). Deaf citizens are granted the right to services both under section 504 of the Rehabilitation Act of 1973 and under the Americans with Disabilities Act.

Despite the prevalence of medical assignments within the typical work schedule of many interpreters, there are relatively few comprehensive resources to guide interpreters wishing to work in this area, and little research on effective practices. The intent of a literature search was to locate resources; initial inquiry focused on sign language interpreting only, and expanded to address spoken language interpreting as well. Studies found were written from the perspective of interpreter practitioners, interpreter educators, linguists, and health care providers. This is a review of information gleaned from those sources.

Deaf patient perceptions.

Until recent years, sign language interpretation studies specific to health care settings have been relatively scarce. One early study of sign language interpretation during a medical interview detailed an analysis of two certified interpreters’ work in medical interviews between a nurse and a Deaf patient (Cokely, 1982). This study found errors of perception, memory, performance and meaning, and suggested strategies for preventing such errors from occurring.

Several studies published in health care journals have addressed the experiences of Deaf people in medical situations. Steinberg et al. (2006) used focus group discussions in three U.S. cities to research Deaf people’s health care experiences. Participants said that they communicated best when “medically experienced certified interpreters” were provided, but that these were “infrequently available” (p. 261). Themes that emerged from the focus groups included Deaf patients’ skewed understanding of the health care provider’s instructions and their sense of fear in medical settings. The latter included both a fear of the consequences of miscommunication and a fear of letting health care providers know that the communication was inadequate. Likewise, participants were fearful of changing doctors, as a new doctor might be reluctant to pay interpreters. One reported that a doctor had commented, “The day I have to hire an interpreter is the day I stop having deaf patients” (p. 263). Participants also reported a sense of mistrust, and a feeling that some providers disliked working with Deaf people. They felt frustrated that, in their view, Deaf people received a different level of care than non-deaf people did. The authors of the study concluded that Deaf people who use American Sign Language have much in common with members of other linguistic minority groups: limited access to English communication, infrequent contact with health care providers who know their language and culture, and the frequent necessity of using family and friends as interpreters. Where Deaf and signing health care professionals are available, Deaf patients prefer direct communication over interpreted encounters with non-deaf medical providers.

In another study, Steinberg et al. (2002) interviewed 45 Deaf women on their perceptions of access to health care. These women exhibited a lack of knowledge of health issues, and reported negative health care experiences and insensitive behaviors on the part of providers. They tended to avoid health services because of previous negative experiences. The authors recommended the development of special resource materials, improved prevention strategies targeted specifically to Deaf people, and the development of self-advocacy skills among the Deaf population. In one of the focus groups held in the northeastern United States, a woman explained that having an interpreter available meant the difference between a hysterectomy and a more conservative treatment that would leave her with the ability to bear children (p. 735). The women in these studies also expressed frustration at the difficulty of scheduling interpreting services, and the subsequent delays this caused. Some avoided seeking necessary treatment because of this.

In Boston, group interviews with Deaf and hard of hearing people found providers’ conflicting assumptions about deafness to be a major source of distress in medical encounters (Iezzoni , 2004). Physicians often questioned Deaf patients about the cause of their deafness despite the fact that it was unrelated to the health problem that had brought them to the office. Participants felt that some doctors did not respect their “intelligence, motivation, and desire to understand and participate in their health care” (p. 356). They reported that doctors often did not understand that providing communication access was the responsibility of the health care provider, and that they complained about the costs or inconvenience of obtaining interpreting services. Doctors were also unaware of the need to have an interpreter with experience and knowledge in medical settings. Another issue in the disagreement with providers over interpreting services involved time: Deaf patients typically expressed the need for more time than their clinicians could or would provide (p. 359). Doctors often believed that note writing and lip reading were more effective than they actually are.

In a study reported in the journal Family Medicine, questionnaires were used to determine Deaf women’s satisfaction with their prenatal care (O’Hearn, 2006). The study found that “Deaf women’s expectations about provision of interpreter services being met or exceeded was significantly associated with overall satisfaction” (p. 712). Deaf women saw a doctor’s willingness to provide an interpreter as a sign of his/her concern for them. The journal article, however, added, “Even providers who recognize a deaf patient’s preference for sign language fail to use interpreter services regularly” . Harmer (1999) noted that health care providers have historically resisted using interpreters, and suggested three reasons: They may not understand the extent of communication barriers; they may see their inability to communicate as a failure on their part; or they may fear cost, violation of patient confidentiality, or the potential of an interpreter to become a witness in a malpractice case (pp. 96-97).

In a British study published in 2000, Ubido et al. found that fewer than one in ten Deaf women understood what the doctor said to them if there was no interpreter present (p. 247). The women believed that non-deaf health care personnel were not able to understand their needs, and that their access to information was reduced. They also expressed anxiety over their experiences in waiting rooms, as they were unable to hear their names being called.

Another study in northwestern England reported that of 98 Deaf adults surveyed, more than half preferred to communicate with their doctors via a professional sign language interpreter, but that only 17% had actually had one provided (Reeves & Kokoruwe, 2005, p. 95). One third reported that they were not sure how well their doctor had managed their case, and did not fully understand their doctor’s advice or what they were to do next. A frequent concern was about medication: inadequate information about it, whether the correct medication had been prescribed, or whether they were using it correctly. The study concluded that “… the single change that would produce the greatest benefit for the largest number of deaf patients is the routine provision of sign language interpreter support for all who desire it” (p. 105).

In addition to communication barriers, it is common for Deaf patients to have limited medical vocabulary with which to communicate with health care providers. Bat-Chava et al. (2005), reporting on HIV/AIDS care and prevention among Deaf and hard of hearing people, found three barriers to Deaf people’s understanding of the disease: low education level, limited English proficiency, and limited communication with medical providers. Berry and Stewart (2006), in an article advising nurse practitioners on communicating with Deaf patients, stated that most nurse practitioners are unaware that Deaf people struggle with English, an observation that is likely true of most health care providers. Harmer (1999) explained that medical jargon causes problems for Deaf patients because most have limited health care knowledge and because doctors tend to use complex vocabulary and phrases in their explanations, rarely using visual information. Written materials given to hospital patients require, on average, an 11th grade reading level, and letters from doctors to patients are often written at a 16th grade level. It is generally acknowledged that the average Deaf high school graduate reads at a 4th or 5th grade level. Harmer also reported that, in 1995, a survey indicated that 60% of doctors assumed that 85% of English words could be speech read.

In addition to difficulties with English, the average Deaf person has fewer opportunities for health education than most non-deaf people have. This results in less initiative to seek answers, less assertiveness, limitations on the types of medical care sought and reduced quality of services received (Harmer, 1999, p. 80). McEwan and Anton-Culver (as cited in Harmer, p. 80) reported that Deaf patients were less likely than other non-English-speaking patients to try to re-explain when providers failed to understand them. In a 1991 survey of Deaf and hard of hearing students, Deaf students exhibited limited knowledge of medical terms, could not properly respond to emergency situations, and were unable to understand prescriptions (p. 82). Similarly, Deaf people may have a poor understanding of the health care system and their own responsibilities for their care (p. 85). In childhood and adolescence, health care encounters are often handled by non-deaf parents, leaving Deaf patients with little awareness of their own medical history or of how the system works.

Non-deaf patient perceptions.

Sign language interpreters and Deaf people themselves commonly see the Deaf community experience as unique. However, research indicates a number of parallels between the experiences of Deaf patients and those of other non-English speakers. There is a body of research reporting on issues that arise in interpreted encounters between non-deaf second-language users and health care providers. Many of these studies relate to the quality of interpreting. For example, Prince (1986) analyzed questions in interpreted doctor-patient conversations and found distortions in three categories: interpreters answering questions for the patient; incomplete translations of multi-part questions; and incorrect translations, primarily due to mishearing, misunderstanding of technical terms, and failure to check the accuracy of information before relaying it.

Flores et al. (2003) reviewed interpreted outpatient pediatric visits facilitated by Spanish-speaking interpreters. Interpreters included both professional interpreters and ad hoc interpreters, that is, nurses, social workers, or family members, and averaged 31 errors per encounter. Most common were errors of omission, 63% of which had possible medical consequences. Errors in word or phrase choice were most often (73%) related to medical terminology. These included incorrect dosage, frequency or mode of administering medications, and omitting relevant information on drug allergies or medical history. The most serious errors were in interpretations by ad hoc interpreters. Other researchers, however, have questioned Flores’ categorization of some utterances or omissions as errors, arguing that they may represent a meaning-based rather than a literal, conduit model of interpreting (Hsieh, 2006, p. 4).

Rivadeneyra (2000) suggested that both health care providers and non-English-speaking patients may alter their behavior in ways that stand in the way of developing a trusting relationship, perhaps resulting in doctors’ misunderstanding of patients’ symptoms, and decreasing the likelihood of patients following doctors’ recommendations (as cited in Angelelli, 2004, p. 21).

Although issues arising from encounters between non-deaf health care providers and Deaf patients and between health care providers and non-English-speaking patients are very similar, Iezzoni (2004) pointed to one important difference: Deaf people are more concerned than non-deaf second-language users when doctors question their intelligence. This is likely due to the long history of oppression and discrimination, and an education system that has historically linked deafness with low intelligence (p. 361). Writing about health care providers’ expectations that Deaf patients will communicate easily by writing or speech reading, Harmer (1999) quoted Lotke (1995), “No other subset of Americans who use English as their second language are expected to do this, nor are they presumed to be retarded (sic) when they fail at these efforts. Deaf people are expected to do both” (p. 96).

The majority of medical diagnoses are made based on a medical history taken during a conversation between doctor and patient (Harmer, 1999, p. 73). According to Byrne and Long (1976, as cited in Angelelli, 2004, p. 75), a typical medical consultation consists of six phases: establishing the doctor-patient relationship, finding out the reason for the visit, a verbal and/or physical examination, consideration of the patient’s condition, explanation of the treatment or further investigation, and termination. Interpreters are a vital part of this process.

In addition to listing typical health-related settings, Stewart et al. (2004) reminded readers that due to increased opportunities for Deaf people, interpreting may also be done between a Deaf health care professional and a non-deaf patient, or in the education and training of Deaf health care professionals. Health-related occupations in which Deaf people are involved include general medicine, nursing, dentistry, physical therapy, chiropractic, podiatry, osteopathy, and veterinary medicine. Woodard (2007), for instance, discussed the provision of oral interpreting service to a Deaf medical resident (p. 8).

A few articles address interpreting in specialty areas of medicine in more detail. Martinez (1999) discussed preparation required for interpreting childbirth, proposing a series of questions an interpreter should ask him/herself as well as some for the Deaf patient (pp. 10-11). Reporting in the April 2003 RID Views, Cumsky Weiss and Schornstein described their experiences working as a Deaf-hearing team of interpreters for childbirth. The mother-to-be requested the team, as she felt she would be more comfortable with the ease of communication a Deaf interpreter could provide. The article details the process of interpreting the birth, and explains some of the logistics the interpreters faced in terms of ways to interpret effectively without hindering the operations of medical equipment and personnel (p. 6).

Bailey and Rockhill (1997) discussed interpreting in hospice, pointing out the importance of understanding the hospice philosophy and the interpreter’s role in this setting as a member of the hospice team (pp. 41-50). Under the category of hospice interpreting, some situations are similar to those in other medical settings, including visits from nurses, doctors or social workers; medical exams; physical therapy; counseling; and physical therapy. However, interpreters in this setting also must face the patient’s death, the pronouncement of death and the preparation of the body. The article describes Sign Language Associates’ Hospice Services, and the specialized education necessary before interpreters work in this setting. Training covers the hospice philosophy, the process of death and dying, the hospice process, family dynamics, grief, stress during terminal illness, medical considerations, the interpreter’s role, safety and emotional considerations, and personal feelings and values related to death and dying.

Legal issues.

Provision of sign language interpreting services in health care settings falls under two laws. Section 504 of the Rehabilitation Act of 1973 requires that access be provided in federally funded agencies, and the Americans with Disabilities Act, signed into law in 1990, requires access in “public accommodations,” including doctors’ offices.

Despite these laws, Deaf people continue to encounter difficulties in gaining communication access. Steinberg et al. (2002) commented, “Despite a decade of legal mandates and case law supporting inclusion, as well as cost-benefit ratios that favor full access to care, continued difficulties are reported when deaf consumers attempt to access health care” (p. 740). Geer (2003) reported that Deaf people file many ADA complaints that they have received accommodations they felt were inadequate (p. 135). Examples include providers asking a Deaf patient to bring a friend or relative to interpret, using a staff member who can fingerspell to communicate, and hiring an incompetent interpreter. Both the ADA and Section 504 of the Rehabilitation Act of 1973 require that interpreters be provided to Deaf sign language users. Depending on the complexity of the issues under discussion, however, there may be situations in which an interpreter is not required.

Some sources in journals for medical professionals have reported on outcomes of lawsuits related to provision of interpreter services with Deaf patients. For example, one article reported on a successful discrimination suit against a medical facility that attempted to use a staff member who knew a little signing instead of waiting for a professional interpreter (Legal Eagle, February 2007). In this case, the patient collected damages for pain and suffering for the time during which the surgery consult went ahead despite the hospital’s refusal to provide a professional interpreter. The article pointed out that although courts have not made it entirely clear whether a certified sign language interpreter is always required, the federal regulations do say that the facility should “give primary consideration to the requests of the disabled (sic) individual” (p. 3). However, an article in another issue of the same nursing association newsletter reported a different case in which a Deaf patient’s teenaged children were asked to interpret for their father, but were unable to sign well enough to do so. The hospital tried to contact a professional interpreter, but could not locate one. The court held that in order to prevail, the complainant would have to prove that the lack of appropriate interpreter service resulted from the medical facility’s “deliberate indifference” (May 2007, p. 5).

Spoken language interpreting services for non-English-speaking patients are governed by Title VI of the Civil Rights Act of 1964. Some articles intended for the health care community have reported that non-deaf patients who speak languages other than English face some of the same barriers to care as Deaf patients do. For example, in a case involving a Spanish-speaking laborer, the court awarded damages for the loss of sight in one eye due to inadequate treatment of an injury. The doctor spoke with an interpreter by phone, but did not make use of the service to talk with the patient, resulting in inadequate communication (Legal Review and Commentary, 2003).

HIPAA and privacy issues.

The Health Insurance Portability and Accountability Act (HIPAA) Public Law 104-191, passed in 1996, applies to health information created or maintained by health care providers, and limits who may see private health care information. The website www.hhs.ocr.hipaa gives information on this act as it applies to patients and health care providers. Two articles in the RID Views explain how this act applies to interpreters. According to Agan (2004), the law applies to health information in any form or medium. Patients must be notified of the law, and notification must be documented (pp. 1, 24). HIPAA addresses the patient’s right to have access to his/her own health records, and to request corrections or submit a written statement of disagreement with them if s/he wishes. The patient has the right to an accounting of how the information was used and to whom it was disclosed. Particularly sensitive information is subject to certain restrictions on access, and a grievance process is in place for patients to use if problems arise (p. 24).

Thress (2005), who has experience as both a physician’s assistant and an interpreter, pointed out that interpreters who are not employees of medical facilities fall under the “business associate” part of the law, and have access to patient information only for the purpose for which the medical facility collected it, i.e., to provide health care. An interpreter or referral service may use the patient’s name, contact information, and generally identifiable health information for business purposes in the provision of service. Thress stated that interpreters need to sign a business associate’s contract, a sample of which is provided on the HIPAA website.

Logistical issues.

Accessing interpreters in a timely manner for medical needs is often an issue, particularly in areas where there is already a shortage of interpreters. Elkins (1993) discussed a process established for dispatching interpreters in emergency situations through the Sign Language Associates, Inc. Emergency Services Division. This service contracts with hospitals, which pay an administrative fee, to provide services in cases of immediate need and short-notice appointments. Elkins’ article points out that, in order to create an effective emergency system, a critical mass of Deaf consumers and interpreters is required. Geographic area, agency structure and interpreter qualifications must also be considered.

Carter et al. (2001) described an on-call system for dispatching medical interpreters in emergencies, developed in response to a class action suit against Connecticut hospitals by the Connecticut Association of the Deaf. The consent decree required that interpreters be provided “within one hour of identifying a patient or companion as needing the services” (p. 1). The system involves both recruiting and assigning interpreters, and providing initial and ongoing interpreter training.

New technology offers other avenues for timely access to interpreters. Swabey and Laurion (2005), in a presentation at the 2005 RID Conference, reported the results of a study on the feasibility of video remote interpreting in health care. Hirsch and Mirano (2007), writing in Health Management Technology, reported on the use of video conferencing to provide interpreting services. A New Jersey hospital that serves a high percentage of both non-English speakers and Deaf and hard of hearing people required interpreting services in 46 spoken languages and in ASL during a two-year period. In 2003, after exploring several solutions, the hospital contracted with an interpreting agency to provide interpreting via video conferencing. Among their requirements for the service were on-demand interpretation for both spoken languages and ASL, using one device to handle both. The service had to be easy to use, with information encrypted for HIPAA compliance, and the interpreters had to be “medically trained.” Hospital administrators found the service to be effective, particularly because it “helped realize large financial savings by not employing live interpreters with huge financial guarantees” . The hospital plans to include access to video interpreting with the in-room monitors used for TV viewing, and to extend its use to EMTs in the field.

Quality control: The case for professional interpreters.

Due to the relative scarcity, expense, and difficulty in scheduling associated with professional, medically trained interpreters, health care providers often resort to the use of ad hoc interpreters, typically staff members who know the patient’s language to some degree, or family and friends of the patient. However, the case for using professional interpreters trained in medical interpreting is strong in situations involving both Deaf individuals and non-English speakers.

Writing about sign language interpreting in medical settings, de Vlaming (1999) suggested that a common issue facing Deaf patients is the pathological view of deafness held by the majority of health care providers. The author stated, “…a professional interpreter acquainted with deaf culture can influence and introduce the perception that sign language is not the absence of spoken English…” (p. 14).

As mentioned previously by Flores (2003), errors increase when ad hoc interpreters are used (as cited in Angelelli, 2004, p. 23). Chen (2006), writing about her experience relying on the husband of an Arabic-speaking traditional Yemeni woman to interpret, advocated for the use of professional interpreters, stating that untrained interpreters are “reliably unreliable” (p. 1745). McAleer (2006), discussing Deaf patients’ experiences with health care in Great Britain, stated unequivocally, “Nurses who are not trained interpreters but have some knowledge in BSL (British Sign Language) should not act as interpreters”. Fallat et al. (2007) reported on a survey of members of the American Pediatric Surgical Association, which posed the following ethical dilemma: A doctor must rely on a neighbor to interpret for Cantonese-speaking parents of a six-week-old baby in order to obtain informed consent for surgery on the child. Based on results of the survey, the report recommended the exclusive use of trained interpreters (pp. 129-136). Only one article supported the use of family members as interpreters. Kuo and Fagan (1999), writing about a group of non-English-speaking patients, found that those non-deaf patients felt highly satisfied with and comforted by family interpreters, and may prefer them.

Even when professional interpreters are available, doctors may not avail themselves of their services. A 1996 survey of 165 doctors at a professional conference found that all were unaware of their legal obligations to provide access to Deaf people under the ADA (Harmer, 1999, p. 80). Iezzoni (2004) found that, “When hiring interpreters, physicians often do not seek persons trained specifically in medical sign language” (p. 359). Steinberg et al. (2006) referred to a study published in the Journal of the American Medical Association (Ebert & Heckerling, 1995), which found that doctors used interpreters with Deaf patients infrequently even though they recognized that communication was better when an interpreter was present. An increase in the use of professional interpreters was noted when health care providers were given training in working with interpreters (Karliner, 2004, p. 175).

Medical interpreting is most often done by community interpreters, rather than staff interpreters. Mikkelson (1999) noted in the RID Journal of Interpretation, “Whereas court interpreting is just beginning to emerge as a recognized profession in this country, … other types of community interpreting are far behind” . However, this is changing in the area of medical interpreting.

Mikkelson (1999), a spoken language interpreter, pointed out that two states, California and Washington, have made efforts to require certification for some types of medical interpreting, and medical interpreter associations have been established in California, Washington and Massachusetts (p. 130). California has also taken steps to prohibit the use of children as medical interpreters in some circumstances (Yee et al., 2003).

Not all states have such requirements, and even in states with specific laws requiring the use of professional interpreters, state laws often “do not define what constitutes adequate screening, testing, training and proficiency for interpreters” (Baker et al., 1998, p. 1469). This points to the need for professional standards for interpreters in both sign and spoken languages, which is the subject of a later section of this paper.

Conduit or co-participant: A discussion of interpreting models.

While much has been written on models of interpreting, perspectives on this subject have evolved with the growth of the profession. In health care settings, as elsewhere, research and practice have redefined traditional interpreting roles in the interests of producing more effective communication.

Perhaps the best-known recent discussion of a sign language interpreter’s role in medical interpreting is found in Metzger’s Sign Language Interpreting: Deconstructing the Myth of Neutrality (1999). Metzger introduced her research with this statement: “In discussions of the issue of interpreter neutrality, the anecdotes that interpreters and lay people share suggest that the traditional perception of the interpreter’s role as a neutral conduit of language is at odds with people’s real-life experiences” (p. 1). Her study analyzed two types of medical discourse mediated by interpreters. One set of data was from role-plays of medical interviews facilitated by student interpreters, and the other was from actual medical interviews facilitated by a professional interpreter. In addition to translating statements made by the health care provider and the patient, both groups of interpreters were found to initiate statements on their own. These included “source attributions,” i.e., indicating who was talking, repetitions, requests for clarification, dealing with interference, and calling for the attention of one of the parties (pp. 114-122). Her findings were similar to those in Roy’s (1989 & 1993, as cited in Metzger, 1999) analysis of interpreted dialogue: Interpreters participate in the discourse by regulating turns, and by altering discourse to accomplish participants’ goals.

Studies on spoken language interpreting have found similar results. Wadensjo (1992) studied medical interviews interpreted by spoken language interpreters and categorized their performances as “relaying,” i.e., conveying what the parties intended to say, and “coordinating” (pp. 18-19). Coordinating functions include asking for clarification, prompting a response or turn from one of the parties, explaining what one party means, or explaining that one party doesn’t understand the other. Angelelli (2003) proposed the term “visible co-participant” to describe the interpreter’s role, in contrast with the invisible, completely neutral role traditionally ascribed to interpreters and still commonly promoted in professional organizations of interpreters and in interpreter education (pp. 3-26).

In her book, Medical Interpreting and Cross-Cultural Communication, Angelelli (2004) noted that, due to the lack of a “theoretical underpinning to account for the special type of interaction that occurs in a medical setting,” standards of practice for interpreters are often based on those for court or conference interpreting, valuing accuracy over goal, intent and context, and seeing the interpreter as a conduit (pp. 2, 7). She observed and interviewed spoken language interpreters in a California hospital who had a great deal of experience in medical interpreting, but little formal training. Angelelli found that the interpreters both saw and conducted themselves as “co-constructors to the interaction,” rather than as invisible interpreters (p. 7). The interpreters actively managed issues of power and solidarity, and the asymmetrical relations between speakers of dominant and less dominant languages. She described the interpreter’s role as “opaque co-participant” rather than “transparent language modem” (p. 11). She pointed out that interpreters accomplish this by means of “text ownership,” i.e., saying something not originated by one of the parties to the encounter, in response to social factors such as the patient’s ethnicity, level of education, or socio-economic status (p. 76). She proposed a continuum of interpreter visibility that ranges from low to high, with a corresponding impact on the medical or personal information involved. Interpreters in this study used a variety of metaphors to describe their roles as they saw them: bridge, detective, diamond connoisseur, and miner, the last three referring to their perception of the need to locate relevant information amid an extended response to a health care provider’s question (pp. 130-131). Wadensjo’s (1992), Metzger’s (1999), Roy’s and Angelelli’s research all showed that an interpreted conversation is necessarily “triadic,” i.e., the interpreter is an active participant in a three-party conversation (p. 4).

Dysart-Gale (2007) pointed out that the view of interpreters as conduits is based on the “transmission model of communication” (p. 240). The medical discipline has traditionally followed this model as well: The doctor talks and the patient listens (p. 241). The author suggested that a more appropriate model for both parties involved is the “semiotic model,” which envisions meaning evolving through the collaboration of the participants. Writing about spoken language interpreters, Dysart-Gale proposed additional roles: clarifier, cultural broker, and patient advocate (p. 239). As clarifier, the interpreter might add information when a cultural difference renders the message unclear. An interpreter acting as cultural broker would provide a cultural framework that allows the receiver to understand the message, and an interpreter in an advocate role might act on behalf of the patient outside of the medical interview, with the goal of promoting quality of care as well as quality of communication. Dysart-Gale added that “role expansion” is controversial, and that some fear it is tantamount to “practicing medicine without a license” (p. 240).

Araujo-Lane and Phillips mentioned that interpreters run the risk of blurring the boundaries between interpreting and medical practice (p. 171). They suggested that interpreters need to explore the concepts of impartiality and transparency and find a “professional center,” which allows them to be accurate and ethical while being transparent and aware of “a complex dynamic that involves understanding themselves, the patient’s culture and the U.S. health care system” (pp. 167-173). According to Solomon (1997), to achieve transparency interpreters must explain to health care providers the difficulties they encounter in translating a concept, and negotiate ways in which it might be adapted to make it understandable (p. 91).

Metzger (1999) recommended that a similar strategy be used toward Deaf patients. Arguing that one issue is the differing schema between health care providers and Deaf patients, she suggested that interpreters should provide information about the interpreted interview to both parties so that all have a similar schema (p. 197). Interpreters need to recognize that, although they cannot include their own opinions and ideas in their interpretations, they cannot as humans be entirely impartial either. In the field of sign language interpreting, a well-known article by Charlotte Baker-Shenk (1991) entitled “The Interpreter: Machine, Advocate or Ally?” reminds interpreters that they cannot be completely neutral. They must be aware of the impact of the choices they make, and make responsible decisions (p. 120ff).

Although there is little research on the actual behavior of sign language interpreters in medical settings other than Metzger’s work, there is research on spoken language medical interpreters’ behavior. Kaufert and Putsch (1997, as cited in Angelelli, 2003, p. 6) found that interpreters expanded and adapted health care providers’ communication, provided cultural explanations and advocated on behalf of patients. Hsieh (2006) studied 26 professional spoken language interpreters who had completed 40 hours of training developed by the Cross Cultural Health Care Program (p. 5). The author found that the interpreters saw themselves as part of the health care team, and tailored their communication strategies to the goal of diagnostic efficacy, for example, by “editorializing” information to emphasize key medical points, seeking information on their own without a prompt from the health care provider, and volunteering medical information to patients. “Editorializing” took the form of deciding whether or not information provided by the patient had medical value before passing it on to the provider, or editing the provider’s statements to more efficiently elicit information from patients (p. 7). Interpreters also substituted medical concepts for patients’ culture-specific comments about their illnesses (p. 28). When the provider left the room, they often summarized, explained, or repeated previous information for the patient. Occasionally they even went so far as to volunteer information on their own, such as suggesting an alternate treatment or discussing their own experience with a disease. The researcher concluded that the interpreters were acting on their own preconceived notions of doctors as authority figures, rather than on an actual assessment of the current interaction, causing them to over-emphasize the information-gathering aspect of the encounter at the expense of the doctor’s goal of establishing a relationship with the patient (p. 23). The behaviors of the interpreters in Hsieh’s study contrast sharply with the model most sign language interpreters follow. For example, Neumann-Solow (1981) advised interpreters to leave explanations of terms to the medical professionals (p. 6).

Often, the difficulties interpreters are responding to when they deviate from the neutral role have to do with conflicting expectations or with cultural differences between provider and patient. A common example, familiar to ASL-English medical interpreters, is the cultural difference between a provider who expects a brief answer to a question about the current illness and a patient whose culture requires that an explanation of the present circumstances be rooted in past events. Spanish speakers, like ASL users, often respond with narratives rather than one-word answers (Sanheim, 2003, p. 35). Mediating culture and world-view are challenges both spoken and sign language interpreters face.

Interpreters and cultural differences.

According to Shuy (1976), problems that arise in medical interviews can be attributed to differences in linguistic and cultural backgrounds and to different goals and understandings of the interaction by patients and health care providers (p. 365). Harmer (1999) characterized “health care culture” as emphasizing rapid diagnosis and treatment, efficient use of services, and a minimum of interaction (p. 86). Lee (2002) suggested that differences between patients’ and doctors’ cultural beliefs and values “hinder the establishment of the cooperative partnership” important in a doctor-patient relationship (as cited in Angelelli , p. 19). Cambridge (1999) wrote that dangers are inherent in the interpreted medical encounter due to the participants’ “lack of a common ground within the transaction” (p. 201).

Mindess’ 1999 book, Reading Between the Signs: Intercultural Communication for Sign Language Interpreters, highlights some of the cultural differences between the culture of the U.S. non-deaf majority and U.S. culturally Deaf citizens as they influence the interpreting process. For example, non-deaf mainstream Americans living in a relatively low-context culture value self-reliance and independence (p. 70). In contrast, Deaf Americans live in a more high-context culture, and place more value on the group than on the individual (p. 113). In a telecourse presentation comparing Deaf and non-deaf cultures, Marie Philip (1993) explained that it is customary for a Deaf person to consult others in the group before making an important decision, a practice that would be seen as overly dependent by many U.S. non-deaf majority members. Harmer suggested that some “grassroots” Deaf people may seek out better-educated peers for medical advice (p. 90).

This kind of cultural difference is not unique to the Deaf community. Dysart-Gale (2007) explained that group members might develop their beliefs and attitudes toward disease not from information given by health care providers, but through communicating with their social group (p. 241). Commenting on a study by Kaufert and Putsch (1997) that showed spoken language interpreters making cultural adjustments in their interpretations, Solomon (1997) pointed out that the emphasis in medical encounters is on patient autonomy. However, not all cultures value autonomy. In some cultures, the preferred norm is to allow a spouse, family members or friends to participate with the patient in important medical decisions (p. 89ff).

Mindess (1999) suggested several techniques for cultural adjustment and provided concrete examples, some of which are specifically related to medical settings. She also provided a “mental checklist” that interpreters can use to decide whether an adjustment is needed (pp.189-190). In these examples, “Not only did the interpreters not take over, but by their skillful handling of the situations and elimination of cultural red herrings, they allowed the participants themselves to control their interactions” (p. 188). This is a definite contrast to the practice of interpreters profiled in Hsieh (2006, ), who took a much more directive approach to cultural mediation, resulting in a skewing of the intent of the encounter.

Dysart-Gale (2007) wrote, “Almost by definition, medical interpreting is a service most often provided to socially marginalized groups …” (p. 238). This can affect communication in many ways. For example, Lee pointed out that doctors should not assume that patients will ask questions when they are confused or unsure, and should realize that the absence of questions does not indicate that patients are uninterested in knowing (as cited in Angelelli, , p. 19). Ferguson and Candib (2002) noted that minority group patients, especially those who do not speak English well, are less likely to evoke physician empathy, establish rapport with health care providers, receive sufficient information, and be involved in medical decisions (as cited in Angelelli, , p. 21).

Davidson (1998, as cited in Angelelli, ) suggested that the doctor and the patient have different views of an interpreter in a medical encounter. The doctor sees the interpreter as “an instrument that keeps the patient on track,” and the patient considers the interpreter a “co-conversationalist”. The author concluded that spoken language interpreters align themselves with health care providers, serving as “gatekeepers” for the patients for whom they interpret.

Given the obvious complexity of the medical interpreting task, it is clear that interpreters need preparation before working in this setting. Preparation includes both formal training and education, and knowledge needed for a specific medical encounter. Resources for both types of preparation will be reviewed in a later section of this paper.

Professional ethics and standards.

In both sign and spoken language interpreting, professional standards provide a critical foundation for effective interpreter practice; this is especially true of interpreting in medical settings. Bancroft (2005), as part of a project for the National Council on Interpreting in Health Care (NCIHC), reviewed interpreting standards worldwide, comparing their content (p. vi). Most emphasized consumers’ health and well-being, promotion of the patient-provider bond, and respect for all parties (p. 25). Relying primarily on standards from the International Medical Interpreters Association (http://www.mmia.org/), the California Health Care Interpreters Association (cms.chiaonline.org), and the “Bridging the Gap” curriculum (www.xculture.org), the NCIHC developed a set of standards for medical interpreters (http://www.ncihc.org/). The goal of the standards is to facilitate communication, promote accurate interpreting, support the patient-provider relationship, establish procedures for mediation during the interpreted encounter, overcome barriers to understanding, and promote ethical behavior. Although RID has a Standard Practice Paper entitled “Interpreting in Health Care Settings,” its purpose is more for guidance of consumers than of interpreters (http://www.rid.org/). The organization provides no specific standards for medical interpreting.

Both RID and the NCIHC have ethical codes available on their websites to guide interpreters’ practice. The NAD-RID Code of Professional Conduct, instituted in 2005, includes seven tenets, with “guiding principles” and “illustrative behaviors” for each. The NAD-RID code is intended to cover all situations, including medical. The NCIHC code is specific to medical interpreting, and includes the following standards: accuracy, confidentiality, impartiality, respect, cultural awareness, role boundaries, professionalism, professional development, and advocacy. Unlike the NAD-RID code, NCIHC guidelines specifically mention “cultural context” as a part of the interpreter’s purview, and encourage the interpreter to increase his/her cultural awareness. NCIHC also specifically states that the interpreter “may be justified in acting as an advocate”. The NAD-RID code allows the interpreter to “judiciously provide information or referral regarding available interpreting or community resources without infringing upon consumers’ rights” (Professionalism; Illustrative Behavior, 2.6).

Professional ethics are customarily included as part of sign language interpreter education, and many resources are available to program students and instructors. Although several of these, for example, Stewart and Witter-Merithew (2006), Cartwright (1999), and Humphrey (1999), included medical interpreting among the scenarios in their texts, they offered no specific guidance about how to make ethical decisions in health care settings. However, Gish (1990) specifically addressed ethical decision-making and health care. This book provides exercises in values clarification, gives a historical perspective on health care ethics, discusses specific health care issues such as distribution of health care resources, looks at the impact of stress and illness on communicators, reviews legal issues in health care, and leads students through both decision-making and professional communication activities.

The NCIHC also provides a “Guide to Initial Assessment of Interpreter Qualifications,” published in April 2001, intended to lay out a strategy for assessment of medical interpreters. This guide can be used either in conjunction with other quality assurance measures such as state or national certification, or alone. It includes basic language skills, ethical case studies, cultural issues, health care terminology, integrated interpreting skills, and translation of simple instructions.

RID has a national testing and certification program which awards both a generalist certificate and a certificate for legal interpreters. To date, RID does not certify medical interpreters.

What does an interpreter need to know?

The complex nature of interpreting in health care settings demands that practitioners be well equipped for the task. Napier et al. (2006) described medical interpreting as “diverse and unpredictable” as well as a “high stakes setting” (pp. 111-112). Clearly, preparation is key to working effectively in this setting. A review of writings that covered both sign and spoken language interpreting found general consensus on what interpreters need to know, and on personal characteristics that are important in medical settings.

By far the most commonly cited need for medical interpreters was knowledge of medical terminology (Yaffe, 1999, pp. 1, 12; Barnard, 2005, p. 7; Goldberg, 2003, p. 6; Dower, 2003, p. 3; Napier, 2006, p. 112; Humphreys, 2003, p. 90; Frishberg, 1990, p. 119). The second requirement noted was knowledge of medical tests, treatments, procedures and equipment. Interpreters must be aware of the stages in medical processes, and the relative importance of communication at each stage (Humphrey & Alcorn, 2001, p. 13.35). Interpreters also need to be familiar with human anatomy and with the varieties of medical disciplines, roles of various medical professionals and hierarchies in the health care system. Lest interpreters find these requirements too daunting, Rogers (1999) pointed out that interpreters need not have a degree in medicine or in medical vocabulary to be effective, and should always be willing to ask both patient and doctor for clarification (p. 9). Barnum, quoted in Stewart et al. (2004), suggested that interpreters must be “educated enough in the field of medicine … not to be a doctor … but to be familiar with and comfortable in (the) medical setting…” (p. 110). Interpreters should have a general background in science, and knowledge of common illnesses, and be aware of safety issues that may affect them or their patients. Interpreters should be aware of the influence of culture and power dynamics in medical settings. Emotional issues, such as the ability to bring calm to a stressful situation, the capacity for “being present” for whatever the patient endures, and awareness of the possibility of vicarious trauma, are also important.

Many authors addressed issues specific to medical settings and suggested ways that interpreters could deal with them. One of the most commonly addressed issues was the need for patient privacy or “modesty,” and discussion included interpreter strategies for maintaining visual access with Deaf patients during physical examinations (Frishberg, 1990, p. 119; Humphrey & Alcorn, 2001, p. 31). Steinberg et al., addressing protocols for quickly identifying Deaf patients and providing interpreter services, stressed the importance of gender preference in choosing an interpreter for certain medical procedures (p. 739). Frishberg suggested that the interpreter could step out of the room during the actual exam or procedure, after explanations have been made (p. 120).

Placement of the interpreter within sight of the patient but out of the way of medical professionals, equipment and procedures is often a challenge. As Humphrey and Alcorn (2001) pointed out, an “ideal” placement, with the interpreter near the health care practitioner and both within the Deaf patient’s sight line, is “virtually impossible” in some situations (p. 31). Frishberg (1990) agreed, pointing out that although interpreters are taught to place themselves near the source of information, the best placement in medical settings is not always near the practitioner (p. 120). Modifications in placement may need to be made to avoid hindering the procedure, or because of safety issues that may affect the interpreter.

A few sources dealt with specific kinds of procedures. For example, Napier (2006) explained the particular challenges that arise in eye care appointments: Some procedures, such as vision testing in a darkened room, removing a patient’s glasses, or dilation of the eyes, compromise the patient’s ability to see the interpreter (p. 113). Moxham (2005) discussed interpreting various types of medical procedures, including dentistry, physical therapy, home health care, nursing home care, and many more, pointing out challenges and suggesting ways interpreters may choose to deal with them (pp. 25-52).

Another challenge interpreters face in medical settings is working with Deaf patients who are stressed, worried, in pain, medicated, or physically compromised (Humphrey & Alcorn, 2001, p. 31). Frishberg (1990) suggested that health care providers sometimes need to be reminded that Deaf patients need to see to be able to communicate, and that interpreters need to be brief, clear and avoid fingerspelling with patients who are sedated (p. 121). A striking example of a physically compromised patient is provided in an article addressing end-of-life care needs of Deaf senior citizens (Allen et al. 2002). A Deaf person in hospice care suffering from a brain tumor was unable to sign clearly. A Deaf hospice visitor was able to understand what he was trying to communicate, even though an ASL-English interpreter with 20 years’ experience was not (p. 198). Although this incident did not involve an interpreted event, it highlights the difficulties a Deaf patient may have, as well as the need for Deaf interpreters in the medical settings.

Safety is another topic that several authors addressed. Interpreters must protect themselves from exposure to illness as well as radiation from x-rays, and be careful that their own health does not negatively affect Deaf patients. Humphreys (2003) suggested that interpreters be aware that when health care providers don scrubs, masks, and shoe covers in preparation for a procedure, interpreters should as well (p. 90). Clear plastic masks are available that will allow the Deaf patient to see the interpreter’s face. Interpreters should also be sure that their routine vaccinations are current, and should have a TB test, hepatitis vaccinations, and tetanus shots. Moxham (2005) suggested an interpreter survival kit of sorts, which would include a nametag, hand sanitizer, sensible shoes, an identifying vest, and a copy of the ADA (p. 12).

One point not often addressed in the literature, and often not covered in interpreter education, is the existence of almost 200 types of genetic hearing loss, about one-third of which are part of a syndrome that can produce major health problems (Harmer, 1999, p. 75). Patients whose deafness falls into this sub-category may need more complex health care than other patients.

These are only a few of the challenges interpreters face in health care interpreting, and for which they need preparation. In the next section, resources for medical interpreters and curricula for medical interpreter training and education will be reviewed.

Education and resources for interpreters.

Dealing with the vast array of medical procedures and terminology can be daunting. A number of resources are available for working interpreters who are either actively involved or interested in medical interpreting. One of the most comprehensive is Tamara Moxham’s 2005 book, Deaf Patients, Hearing Medical Personnel: Interpreting and Other Considerations. The book is intended and written for interpreters, Deaf consumers and their families, and medical staff and administrators, and covers protocol for hiring interpreters, including Deaf interpreters; HIPAA; interpreter roles; emergency coverage; ethics; medical context and culture; and specific types of medical scenarios.

In an article published in the Journal of Deaf Studies and Deaf Education, Harmer (1999) has provided an overview of Deaf people and medical care entitled “Health Care Delivery and Deaf People: Practice, Problems, and Recommendations for Change.” This broad-ranging article examines factors affecting Deaf people and health care, reviews literature on the subject and recommends changes.

The Interpreting Handbook for Diagnostic Procedures (1998, 40 pgs.), by Cathy Cochran of the Olathe Medical Center, describes common radiologic diagnostic procedures, such as chest x-rays, bone studies, ultrasounds, and angiographies, giving information that interpreters need to interpret them successfully. For each procedure, the author has explained the purpose of the exam, how the patient is prepared, the position of the patient, appropriate placement of the interpreter, precautions, and special considerations. She has also provided specific information on how interpreters can protect themselves during these procedures, and included a list of common medical abbreviations.

Writing in the RID Views, Barnard provided a very brief list of terms associated with sexually transmitted diseases, giving a definition of each and suggesting that interpreters attend lectures or read up on STDs (January 2005, pp. 1, 15). Goldberg suggested low-cost training options such as workshops and college courses in anatomy and physiology or in Greek and Latin affixes, and further recommended that interpreters watch medical programs on television, particularly those on public or educational channels, paying particular attention to the social dynamic among professionals (January 2003, pp. 6-7). The author also suggested medical dictionaries and laminated pages from medical study guides as useful resources.

Although written primarily for spoken language translators and interpreters, materials available from the American Translators Association (www.atanet.org) can also be helpful to sign language interpreters. This organization, which has a medical section for members, publishes Medical Translating and Interpreting: A Resource Guide: A comprehensive resource for translating and interpreting in the medical field. Among the articles in issues of recent conference proceedings are discussions of specific medical topics. For example, two papers written by a doctor who is also a translator define coronary heart disease, giving symptoms and risk factors and describing the diagnostic procedure and treatment (Rivera, 2004, pp. 141-146); and explain issues and terminology associated with palliative medicine (Rivera, 2003, pp. 161-173). Another summarizes classifications, terminology and treatment of epilepsy (Rosdolsky, 2005, p. 177ff). Philips and Araujo-Lane (2005) offered ideas on how to request clarification in medical interviewing and walked readers through options for interpreting a specific medical term, describing the ramifications of each interpretation (pp. 197-205).

Other resources include Barnum and Siebert’s (1987) Interpreting in Medical Settings: A Student Manual, written for the program in Medical Interpreting at the College of St. Catherine, and Bridging the Gap: A Basic Training for Medical Interpreters (1999) from the Cross Cultural Health Care Program (http://www.xculture.org/). Language-specific resources include Trabing and Metivier’s (1995) Training Manual for Spanish/English Interpreters in Health Care Settings from the North Carolina Primary Health Care Association, and Mikkelson’s (1994) The Interpreter’s Rx: A Training Program for Spanish-English Medical Interpreting.

Swabey et al. (2006) wrote, “Although health care interpreting is one of the most common forms of community interpreting, effective practices for the education of interpreters working in health care have yet to be identified” (p. 59). A few sources suggested topics that might be included in such a curriculum. A survey of medical interpreter training options available for spoken language interpreters in California in 2002 found that programs ranged from 30 to over 360 hours, with most 40 hours long. Two-thirds of these programs required no practicum experience as part of the training. Typical courses included role and ethics, basic interpreting techniques, controlling the flow of the session, medical terminology, professional development and the impact of culture in medical interpreting. Longer programs included more practice interpreting and more analysis of the conversation process (Dower, 2003, p. 3).

The College of St. Catherine established a Health Care Interpreting Program in 1983. According to Barnum (1989), students were required to take Human Anatomy and Physiology, General Psychology I and II, Lifespan Development, Psychology of Adjustment, and Medical Terminology as part of their general education courses. In addition to the language and interpreting skills classes typical of most programs, students were offered classes specific to the medical setting. “Introduction to the Health Care Interpreter Setting” consisted of lectures, tours and observations of medical interpreters, and was designed to help students understand the health care system. “Medical Interpreting” provided an opportunity for students to gain hands-on experience while they continued to learn about the health care system. Each unit also included vocabulary and role-plays related to the topic. Topics included placement, determining appropriate communication mode, job stress, medication, and safety issues. Students also completed practicum hours with a working medical interpreter during this course. After taking “Medical Interpreting,” students took “Mental Health Interpreting,” which included such topics as therapy, sexual abuse and domestic violence, and chemical dependency. This course also included a practicum. The last course in the health care course sequence was a 90-hour practicum. In addition to these courses, the program included “Ethics and Decision-Making for Health Care Interpreters” in which students studied ethical issues in the health care setting (1989, p. 85ff).

Reporting on the emergency dispatch system for sign language interpreters in Connecticut mentioned earlier, Carter et al. (2001) wrote that initial training of working interpreters unfamiliar with medical interpreting included safety and universal precautions, consent forms, radiology and pharmacology, working with deaf-blind people in medical settings, and “Rx for Effective Medical Interpreting” . Ongoing weekly small group classes included case studies, role-plays, films on specific medical topics and question-and-answer sessions. Mentoring on the job, individual weekly sessions, and classes for CDIs and oral interpreters were also provided.

A unique training program was developed to prepare interpreters of spoken Navajo to interpret information related to diabetes, a major health problem among that population. Under the auspices of the Navajo Nation, the project developed a glossary of common terms and concepts, and used case studies to address four common situations: the newly diagnosed diabetic, the patient with poorly controlled diabetes, retinopathy screening, and nephropathology screening and treatment (Nutrition Research Newsletter, pp. 12-13).

Angelelli (2006) recommended that health care interpreter education should aim to develop skills in six areas: cognitive processing; interpersonal issues, such as role visibility/neutrality and power; linguistic factors, such as vocabulary and changing registers to accommodate patient needs; professional issues, such as ethics and certification; settings; and sociocultural issues, such as the impact of the institution and society (p. 25). The author stressed that the current model of interpreter education is based on preparing conference interpreters, but that new models need to “account for the role of the interpreter, so that students understand the agency that they have, how it falls within a continuum of participation or visibility, and what duties and responsibilities emerge from this agency that cannot be denied” (p. 29). Students need to be exposed to medical discourse so that they see the connections between settings, expectations and actual performance. Angelelli recommended “problem-based learning,” of the sort that is used in medical schools, and suggested that students might also benefit from health care communication courses offered in medical schools (p. 35). She suggested the following course sequence: introduction to medical interpreting, language enhancement for medical interpreting, strategies for medical interpreting, the role of the medical interpreter, and a practicum in medical interpreting (p. 38).

A problem-based learning strategy used in many in sign language interpreting programs is the “Demand Control Schema.” Dean and Pollard (2005) defined interpreting as a “practice profession,” like law or medicine, one that requires the practitioner to be able to consider the situation and human interaction in order to work effectively (p. 259). This is in contrast with “technical professions,” like engineering or accounting, in which one needs only knowledge and skills to function well. These authors echoed Roy , Metzger , Hsieh , Angelelli and Wadensjo in their statement, “Our teaching and practice experiences have led us to conclude that the field of sign language interpreting suffers from significant gaps in rhetoric versus defacto practice” (p. 265). In other words, interpreters in real life do influence the flow of communication, and must realize their agency in order to practice effectively. Dean and Pollard proposed the Demand-Control Schema as a framework for decision-making in interpreting. All situations, including medical ones, force interpreters to make decisions regarding the demands of the situation in four areas: environmental, interpersonal, paralinguistic, and intrapersonal. Interpreters may choose to deal with these in active (liberal) or inactive (conservative) ways. Moving too far to either end of this continuum may risk unethical behavior (p. 273).

The Demand-Control Schema has been used in teaching interpreting in general and in teaching medical interpreting in particular (Dean et al. 2003, pp. 1, 10-12). Davis (2005) explained how the interpreting program at the University of Tennessee, working with the University of Rochester, offered an introductory course in Demand-Control Schema followed by a course in medical interpreting (p. 40). In the second course, students shadowed health care providers at the University of Tennessee Medical Center, using the Demand-Control Schema to analyze the settings they observed. Through their observations, they were exposed to basic medical knowledge and terminology, doctor-patient interaction, and a variety of health care settings. Following each observation they researched related medical information, then participated in a “group supervision meeting” in which they discussed their experiences under the guidance of an instructor. Students benefited not only from the knowledge they gained, but also from the opportunity to gain empathy for patients and to understand the health care providers’ perspectives (Dean et al., p. 12).

Metzger suggested that one way to prepare students for future medical interpreting would be a team effort between an interpreter education program and a medical education program that pairs interpreting students with medical students (p. 200). This would also benefit medical students, preparing them to work with interpreters in their future careers, and might well have the effect of increasing usage of interpreting services. Kennedy and Rho (2004) have used professional interpreters in a formal curriculum to teach doctors “triadic interviewing,” that is, interviewing patients using an interpreter, and have found it very successful (p. 557).

This review of literature, though not exhaustive, offers useful insights into the practice of interpreting in medical settings. Many articles both on sign and spoken language interpreting have not been included; there are also video resources, including instructional materials, which are not reviewed here. However, by identifying apparent gaps and needs in the field, this brief survey provides a salient background for further research and study.

Within health care settings, second-language patient experiences appear similar in many respects for both Deaf and non-deaf individuals. Despite the parallels, however, differences rooted in a history of oppression produce a unique Deaf community experience.

A discussion of the variety of medical interpreting types and settings reinforces the complexity of this interpreting specialty. Ongoing challenges to effective practice include both legal issues and logistical concerns. Despite the existence of laws mandating language accommodations for second-language users, communication access remains elusive or sporadic in many instances. Logistical complications include timely scheduling of interpreters for emergencies, service provision to remote locations, and the need to bolster interpreter numbers to meet service demand. Emerging innovations, such as on-call dispatch systems for medical emergencies, offer some practical solutions, and new technology promises further gains, especially in the area of video remote interpreting.

A number of studies have described the benefits of using educated, professional interpreters in medical settings, and promoted their exclusive use with both Deaf and non-deaf second-language populations. In reality, however, quality assurance remains a concern. Health care providers hire professional interpreters inconsistently, a problem that indicates a need for further education and awareness.

Examination of the interpreter’s role has included a look at both traditional and more recent interpreting models, and reveals active participation to be a necessary function of working in health care. Given the unique needs of the setting, an interpreter cannot operate strictly as a conduit, nor be completely impartial.

Although professional and ethical standards are available to guide the general practice of interpreters, standards and guidelines specific to signed language interpreters in the medical settings are still evolving. Neither interpreter assessment tools nor certification for medical settings are widely available, although strides are being made. This is an area to be further developed.

For both spoken and sign language interpreting, studies show that cultural and linguistic differences within the interpreted medical event can influence interpersonal dynamics and shape the outcome of the encounter. Problems arising are often due to differing cultural norms, and the onus falls to the interpreter to make the adjustments required for accurate communication.

As emphasized throughout the review, adequate education and preparation are necessary for effective interpreter performance, and learning opportunities tailored specifically to medical interpreting offer the greatest benefits. Interpreters need to be equipped with not only a basic medical background and an awareness of medical procedures, but also a thorough understanding of the emotional and safety issues inherent to health care settings. Additional needs in this area include the development of comprehensive curricula, and identification of best practices for medical interpreting.

Overall, this survey of the literature on medical interpreting both in ASL and in spoken languages confirms that interpreting in the medical setting is a complex, challenging and crucial task, and one the requires intensive preparation and education. There is a great deal of research, curriculum development, and learning still to be done. Further exploration of this subject is essential to expanding the knowledge base, developing quality learning opportunities for medical interpreters, and ensuring more effective communication access for Deaf citizens within the health care system.

Araujo-Lane, A., & Phillips, V. (2003, November 5-8). Understanding the power of a medical interpreter. Paper presented at the 44th Annual Conference of the American Translators Association, Phoenix, AZ.

Bailey, J. L., & Rockhill, J. A. (1997). Interpreting in the hospice setting. Paper presented at Celebrating the Vision: RID in the 21st Century. Proceedings of the 15th National Conference of the Registry of Interpreters for the Deaf, Long Beach, CA.

Elkins, E. F. (1993, August 10-14). Emergency services: A new era. Paper presented at A Confluence of Diverse Relationships. Proceedings of the 13th National Conference of the Registry of Interpreters for the Deaf, Evansville, IN.

Geer, S. S. (2003). When “equal” means “unequal” and other legal conundrums for the deaf community. In C. Lucas (Ed.), Language and the law in deaf communities. Washington, DC: Gallaudet University Press.

Gish, S. (1990). Ethics and decision-making for interpreters in health care: A student manual. Minneapolis, MN: College of St. Catherine.

Swabey, L., Alvarado-Little, W., & Taylor, M. (2006). A united front? Opening a dialogue on effective practice for educating interpreters to work in health care settings. Paper presented at A New Chapter in Interpreter Education: Accreditation, Research & Technology. Proceedings of the 16th National Convention of the Conference of Interpreter Trainers, San Diego, CA.

Swabey, L., & Laurion, R. (2005). Video remote interpreting in health care settings: Truth or dare. Paper presented at Bridging Cultures, the National Conference of the Registry of Interpreters for the Deaf .

Thress, R. (2005, April). HIPAA and the new rules: Have you signed your contract yet? RID Views, 22.

Wasongarz, D., et al. (1994). Bioethics and the intermediary role of interpreters: Negotiating language, culture and emotions. Paper presented at the Conference of the American Anthropological Association.

Woloshin, S., et al. (1995). Language barriers in medicine in the United States. Journal of the American Medical Association, 273(9), 4.

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Draft Bibliography

Medical Interpreting: Signed Languages ~ Print Resources

Developed by J. Moore and L. Swabey
CATIE, College of St. Catherine/NCIEC
DRAFT ~ 2007

Barnett, S. (2002) Cross-cultural communication with patients who use ASL. Family Medicine, 34(12).

Brener, T.H. (1990) The relationship between the use of sign language interpreters and the effectiveness of communication in the medical encounter. Ph.D. Thesis (available from Eastern Michigan University Library, Gallaudet University, RIT.)

Fisch, M. (2001) Interpreting practices in healthcare: An investigation of differences across trained and untrained interpreters in initial assessment interviews, within the field of speech language and hearing therapy. University of Capetown, South Africa: Thesis/Dissertation.

Hughes, G. Hudgins, B. & MacDougall, J. (2004) Using telehealth technology to improve the delivery of health services to people who are deaf. In Conference Proceedings: Annual International Conference of the TEEE Engineerig in Medicine and Biology Society, 4, pp. 3084-3087.

Meyer, B. (1998) Interpreter-mediated doctor-patient communication: The performance of non-trained community interpreters. Paper presented at the Second International Conference in Legal, Health and Social Service Settings, Vancouver, B.C., Canada (Critical Link Two).

Families, cultures and AAC augmentive and alternative communication (1999) Southeast Missouri State University & the University of Arkansas for Medical Sciences (computer file: interactive multimedia).

The Critical Link www.criticallink.org/English/linksmedical.htm (links to Cross-Cultural Health Care Program, California Healthcare Interpreters Association, Diversity Rx, New South Wales Multicultural Health Communication Service, and National Council on interpreting in Healthcare, each of which links to relevant information on medical interpreting).

At the Critical Link 7 conference in Toronto in June 2013, Therese-Marie Mirande facilitated a session on the resources that the National Council on Interpreting in Health Care provides for interpreter educators. Here are a list of some of those resources.

Domains and Competencies

A Medical Interpreter: ASL/English is a credentialed professional with national certification, CDI or CSC or CI and CT or NIC Advanced or NIC Master (1), who facilitates communication between users of signed and spoken languages in health care settings throughout the life span. Qualifications include:

Bilingual fluency in English and ASL including the ability to produce and comprehend sociolinguistic variation.

Understanding of linguistic, social and cultural influences that impact health care interactions (e.g., specialized vocabulary, discourse styles, language register, dynamics of power and prestige between interlocutors, and triadic communication).

Adhering to the Registry of Interpreters for the Deaf and the National Association of the Deaf Code of Professional Conduct and familiarity with the NCIHC code of ethics.

Balancing the need for maintaining professional distance with empathy and flexibility.

Understanding underlying practices of various health care delivery systems and the role of self and others on the health care team (e.g., employing CDIs, Deaf Community Healthcare Workers [CHWs] and advocates when they can enhance the communication).

All of the following credentials are offered by the national Registry of Interpreters for the Deaf in the United States: CDI-Certified Deaf Interpreter, CSC-Comprehensive Skills Certificate, CI-Certificate of Interpretation, CT-Certificate of Transliteration, NIC-National Interpreter Certification.

Domain 1. Health Care Systems

The interpreter demonstrates knowledge of the health care context including differences between public and private health care systems and hospitals, various venues where medical care is provided, common diagnoses and treatments, institutional hierarchy, and roles and responsibilities of health care personnel.

The interpreter demonstrates knowledge of medical terms, procedures, and protocols of the health care system and specialized environments.

The interpreter discusses the role and function of the interpreter as part of the health care team in a professional manner.

The interpreter applies knowledge of health care systems and the rights and needs of Deaf, deaf-blind and hard of hearing people to affect positive and systemic change (e.g., health care literacy).

Domain 2. Multiculturalism and Diversity

The interpreter exhibits behaviors and practices that demonstrate respect for patients and healthcare providers from diverse backgrounds and with diverse beliefs, striving to provide interpreting services that respect the cultures, values and norms of the consumers involved. The interpreter demonstrates strategies for working with consumers for whom healthcare settings provoke increased anxiety.

The interpreter provides information to health care professionals regarding the importance of creating a visually accessible environment for Deaf, deaf-blind and hard of hearing people (e.g. communication boards, use of lights, avoid responding through an auditory intercom when patient presses call button).

The interpreter demonstrates strategies for working with Deaf people and health care professionals who have had prior negative experiences with access to health care (e.g., experiences of discrimination due to socioeconomic status or cultural beliefs).

The interpreter assesses and accommodates varied levels of language competency, knowing when to call in a specialist such as a CDI or Deaf Community Health Worker (CHW).

The interpreter demonstrates respect for consumers’ autonomy allowing consumers to make their own decisions.

The interpreter maintains awareness of changes in the communities in which s/he works, such as an infusion of immigrants, and is able to interpret in medical settings effectively for patients and providers with varying cultural and religious needs.

Domain 3. Self-Care

The interpreter recognizes issues in the work environment that may create distress within oneself and employs strategies for dealing with feelings (e.g., vicarious trauma).

Mental, emotional, social and spiritual wellness (e.g., journaling, exercising, seeking support from a trusted confidante or professional counselor).

The interpreter demonstrates awareness of personal safety practices in health care settings (e.g., stands behind a shield when x-rays are taken, wears a mask when a patient has an airborne disease, applies universal precautions).

The interpreter demonstrates physical and emotional stamina necessary for interpreting in health care settings, including how and when to call in a team member (e.g., procedures that last several hours such as births or procedures with intense smells).

Domain 4. Boundaries

The interpreter declines medical interpreting assignments that are beyond his/her capability, be it emotional, physical, or level of language competence.

The interpreter limits personal involvement with all parties during interpreting (e.g., not sharing or eliciting overly personal information in conversations with patients or health care providers).

The interpreter separates one’s own personal values and beliefs from those of other parties (e.g., interprets all reproductive choices to Deaf patient regardless of own beliefs).

The interpreter does not assume the right to make decisions for the patient and his/her treatment or healthcare plan and is aware of how the interpreter’s use of language can subtly change or influence decisions.

The interpreter works as part of an extended interpreting team sharing important information, language approaches, etc. with other interpreters serving the same patient, allowing for continuity of service.

The interpreter discloses or attempts to avoid potential conflicts of interest where professional boundaries may be compromised (e.g., does not interpret for a family member or close friends, may decline to interpret for a person’s performance appraisal at work if that person is a regular consumer in a health care setting).

The interpreter promotes patient autonomy (e.g., does not offer patients a ride home, or offer to pick up patients’ prescriptions).

The interpreter determines when it is appropriate to protect an individual from serious harm (e.g., intervenes on behalf of a patient with a life-threatening allergy, if the condition has been overlooked).

The interpreter consults with professional colleagues on matters of importance and concern (e.g., other interpreters, members of the health care team), and suggests ways to overcome communication or language challenges using a Deaf Interpreter, social worker, Community Health Worker (CHW) or patient advocate

The interpreter works as part of an interdisciplinary team to ensure effective communication.

The interpreter obtains relevant information prior to the specific interpreting assignment and has the skills to sufficiently research the background on various procedures and treatments to allow effective visual representation of the procedures.

The interpreter attempts to obtain appropriately relevant information prior to and during the specific interpreting assignment (e.g., reason for the appointment, reading brochures, studying charts on the walls).

The interpreter possesses a readiness plan for working in various situations such as with refugees and immigrants, for example, who may not have acquired ASL or English (e.g., uses models and pictures, knows when/how to get a CDI or Deaf CHW).

The interpreter maintains a sufficient amount of professional liability insurance.

Domain 6. Ethical and Professional Decision Making

The interpreter applies ethical principles in decision making, and understands the ramifications of decisions (e.g., when to accept or decline assignments).

The interpreter demonstrates awareness of the impact of demographics on decision-making (e.g., Deaf people may be known very well to the interpreter in a small town).

The interpreter demonstrates knowledge that the decision-making processes and the expectation to disclose and/or report certain information may be different between staff interpreters and freelance interpreters (e.g., staff interpreters may have more access to pertinent information and make different decisions than freelance interpreters).

The interpreter has advanced decision-making skills and knows when ethical dilemmas need to be resolved in collaboration with the patient and healthcare provider in order to lead to the best outcome for patient treatment and recovery.

The interpreter recognizes the need for patient privacy and exercises discretion about staying in the room or leaving (e.g., during medical procedures, private family conversations).

Domain 7. Language and Interpreting

The interpreter demonstrates ASL and English interpreting skills, linguistic competency, cultural knowledge and fluency in medical discourse in both English and ASL.

The interpreter is able to interpret both consecutively and simultaneously, understanding the ramifications of each format and demonstrating the knowledge and skills to move effectively between these formats during a single appointment or procedure (e.g. considers factors such as acute care needs and the potential for disrupting a participant’s train of thought when deciding whether or not to use consecutive interpreting).

The interpreter determines when an explanation of a specific interpreting process is required, and provides a rationale for its use (e.g. consecutive interpreting, simultaneous interpreting, or the use of a CDI).

The interpreter adapts the interpretation for age, gender, and culture (e.g., immigrants).

The interpreter adapts for individuals who are not proficient in ASL or English (e.g., uses a CDI when appropriate).

The interpreter communicates assertively in interactions with patients and service providers, in order to render an effective interpretation (e.g., if the health care provider is ready to leave the room before the interpretation is completed, the interpreter may intervene and ask the provider to wait for a moment in case there are questions).

The interpreter demonstrates skills in working as part of a team with CDIs and spoken language interpreters.

The interpreter is able to describe how language barriers can compromise access to health care for Deaf patients and health care providers.

The interpreter strives for accuracy when interpreting between all parties (e.g., knows when to seek clarification of the message).

The interpreter demonstrates strategies for interpreting in settings when the Deaf individual cannot see the interpreter (e.g., x-ray, eye exam, informs the providers that the resulting silence during the event does not constitute agreement).

The interpreter demonstrates strategies for interpreting in situations where the patient may become violent or is restrained (e.g., positioning self with ready access to the door).

The interpreter demonstrates strategies for use of first and third person pronouns and what to do when the health care provider uses the first and third person.

As possible, the interpreter notes on consent forms and legally binding forms that the materials have been interpreted.

Domain 8. Technology

The interpreter demonstrates knowledge of medical technology necessary to accurately interpret a procedure (e.g., use of classifiers for colonoscopy).

The interpreter is knowledgeable about video remote interpreting, pagers, video relay services and other forms of communication technology appropriate or necessary for the health care of Deaf, deaf-blind and hard of hearing individuals.

The interpreter uses information technology to broaden knowledge and research specific topics related to health care.

Domain 9. Research

The interpreter remains current by reading professional journal articles and incorporating new knowledge into practice and shares this knowledge with team members (e.g., other interpreters, mentees).

The interpreter critically evaluates research relevant to interpreting issues (e.g., uses appropriate analytical methods to make inferences linking research to practice).

The interpreter demonstrates awareness of current health care policies.

The interpreter maximizes the commonly available resources in the medical setting (grand rounds, lectures, observation of procedures) that can increase familiarity with the treatments and situations to be encountered.

The interpreter continually seeks available resources in the community (e.g., maintains and adds medical related literature and resources to a personal library).

The interpreter demonstrates awareness of liability issues related to ineffective interpretation with grave errors, including risk to the participants and risk to the interpreter.

Domain 11. Leadership

The interpreter may serve as a liaison between interpreting services and the health care system (e.g., agencies, regional and national interpreting organizations).

The interpreter may serve as a liaison between interpreter education programs and the health care system.

The interpreter provides mentoring and evaluation opportunities to staff and new interpreters in the health care setting (e.g., displays positive role modeling).

The interpreter promotes the establishment of policies and education that improve access for Deaf, deaf-blind and hard of hearing people to health care interpreting services.

The interpreter maintains positive and strong connections to the Deaf community.

The interpreter locates and uses community resources, both Deaf and non-deaf, when necessary to support their work (e.g., patient assistant, ombudsman, social worker, advocate).

Domain 12. Communication Advocacy

The interpreter demonstrates awareness of the political, sociological and cultural implications of advocacy (e.g., does not serve as an advocate when Deaf patients are capable of advocating on their own behalf).

The interpreter demonstrates knowledge of resources locally and nationally that can support a patient’s health care (e.g., awareness of group homes or other facilities and entities that can assist in patients’ health care).

The interpreter demonstrates understanding of health care culture and institutional hierarchy. When faced with patient care discrepancies, the interpreter reports the discrepancy to the appropriate personnel.

The interpreter encourages and supports self-advocacy when possible (e.g., may discuss self advocacy with the Deaf or hard of hearing patient).

The interpreter demonstrates standard and professional responses to common issues that arise regarding provider and patient rights, laws and procedures (e.g., may provide information to a patient about accessing grievance procedures).

The interpreter practices effective timing of providing communication advocacy (e.g., may provide information pre-, during, or post-patient/provider interactions, improve skills and enhance knowledge for how to work with interpreters).

The interpreter may work collaboratively with the Deaf community for advocacy efforts in health care settings (e.g., may present at Deaf meetings and events on health care advocacy issues).

The interpreter demonstrates knowledge of the RID/NAD Code of Professional Conduct and the implications of providing advocacy. The interpreter is also aware of the NCIHC code of ethics and its position on advocacy.

The interpreter provides health care providers with information about interpreting, and refers providers to Deaf, hard of hearing and deaf-blind people who can discuss Deaf culture, deafness, blindness and how the needs of individuals from these communities can be best met in the health care system.

The interpreter may provide family members of the Deaf patient with information about interpreting and may discuss the communication needs of the Deaf person and how to obtain access through interpretation.

The interpreter may provide Deaf, deaf-blind and hard of hearing communities with information about interpreting and how their needs can be best met in the health care system.

Domain 13. Professional Development

The interpreter stays current with practices in health care settings (e.g., immediately aware of universal precaution changes and updates, and may shadow health care personnel for educational purposes).

The interpreter develops and implements annual professional development plans (e.g., assesses gaps in knowledge addressing them with measurable goals).

The interpreter promotes the use of mentors from the Deaf, deaf-blind and hard of hearing communities (e.g., seeks out qualified mentors to assist in professional development activities).

The interpreter develops a portfolio for interpreting in healthcare, including credentials and professional experience (e.g., certifications, research, evidence of workshop attendance, independent studies).

Introduction

The National Consortium of Interpreter Education Centers (NCIEC) was charged, among other priorities, with identifying and establishing effective practices in a number of interpreter work settings, including interpreting in mental health settings. The Consortium members chartered the NCIEC Mental Healthcare Interpreting work team to lead that effort. During 2006-2007, the work team, led by Cathy Cogen, Director of the Regional Interpreter Education Center at Northeastern University, obtained the input of a wide range of content experts in the field, completed a review of the literature, and developed domains and competencies for interpreters working in these settings.
Upon completion of those activities, the work team determined additional input was needed from program administrators and educators in the area of mental health interpreting education. To gather that input, the work team contracted with an external consultant, Karen Dahms. The NCIEC work team leader had identified eight administrators and/or educators who offered instructional programs or media for signed or spoken language interpreters. The interviews conducted in the latter part of 2007 and reported on in February 2008 included the following individuals:
Izabel Arocha
Cambridge College Mental Health Interpreting Certificate Program
Cambridge Health Alliance Mental Health Lecture Series for Medical Interpreters?http://www.cambridgecollege.edu/download/UGinterp.pdfiarocha@challiance.org

Dan Veltri
Interpreting in Mental Health Settings
Treehouse Publicationshttp://treehousevideo.com/store/index.phpDan@treehousevideo.com
?This report provides an analysis of findings of the interview sessions and a summary of each interview. The findings are useful in identifying those competencies, teaching approaches, and resources considered critical to effectively prepare interpreters for work in mental health settings. The findings lend further support to the Mental Healthcare Interpreting Domains and Competencies established by the work team in 2007. The information gathered through the interview process is organized in two primary sections of the report:

Section I – Analysis of the information collected, organized into broad findings.

Section II – Summary of each interview. (Each interview summary has been approved by the interviewee.

Section I – Analysis

Because of the variation among the roles and responsibilities of the eight individuals interviewed and the training and education programs they are responsible for, there was corresponding variation in the type of information reported. Therefore, a summary of each interview and the information collected is provided in Section II of this report. However, there were also many areas of agreement among the interview participants, and a number of common patterns and trends emerged over the course of the interview process. Based on a final analysis of the information collected, it has been organized into the following broad categories of findings and recommendations:

General

Mental Health Interpreting Education and Training Components

Mental Health Interpreting Education and Training Delivery Modes

General

Finding 1 – Need for a National Resource Site

It was interesting to learn that at the time of the interviews, the interviewees were largely unaware of other programs offering specialized training in this area. While each of the participants was extremely knowledgeable with regard to the subject matter of interpreting in mental health settings, they were far less aware of other resources that might be available. Several interviewees inquired about other professionals participating in the interview process, but upon being informed of those participants, were for the most part unfamiliar with either the individual or program. The one exception was the Dean/Pollard Observation and Supervision research project, which was recognized and identified by most as innovative and effective.

In addition, several interviewees indicated the need for materials to be developed that were identified by other programs as already existing. For example, two programs spoke to the need for a DVD of actual Deaf mental health patients in a therapeutic session as a training tool, while two other programs identified such a DVD as already existing and in use in their programs. All of the individuals interviewed were excited about the prospect of a resource site on the subject of mental health interpreting, as envisioned by the NCIEC. All expressed interest in either participating in or being linked through such a site.

Finding 2 – Shortage of Qualified Mental Health Interpreters

It was no surprise that several of the interviewees indicated that their programs had sprung from a ‘local’ awareness of a shortage of qualified interpreters available and trained to work in mental health settings. As an example, two program interviewees indicated issues related to the shortage of qualified mental health interpreters were raised by mental health providers in their state as a critical issue. For those programs, members of the mental health professional community played an active role in developing training and curriculum to address the need. It was also interesting to note that many of the individuals seeking education from the programs participating in the interview process already possessed some experience interpreting in mental health settings. Based on the interviews, it would appear that these interpreters, having encountered the complexities associated with working in mental health settings, were seeking additional education, training, tools and techniques to be more effective.

Finding 3 – Interpreter Roles and Responsibilities

Interviewees stressed repeatedly that interpreting in mental health settings was entirely unique, and therefore required its own set of clearly defined interpreter roles and responsibilities. Further, several of the interviewees indicated they had gathered information or directly received feedback from providers and Deaf consumers that interpreter roles and responsibilities, and hence performance, vary widely in mental health settings. While these interviewees stated the need for clearly defined roles and responsibilities and more standardized norms for interpreter behavior in the mental health setting, the extent to which their program addressed the issue was less clear. When further questioned, some specific examples of educational components designed to reinforce appropriate roles and responsibilities were provided. Those components identified included the following:

Roles and responsibilities related to the interpreter’s participation in the provider/interpreter/patient triad;

Establishing and maintaining communication and rapport with the mental health provider;

Participating as a member of the treatment team versus patient advocate;

Managing personal issues and reactions within the therapeutic session;

Serving as a resource to the provider on issues related to deafness; and

Adhering to applicable legal and ethical mandates and policies related to mental health settings and interpreting in those settings.

Mental Health Interpreting Education and Training Components

Finding 4 – Program Participants

Overall, the programs that participated in the interviews were geared toward experienced interpreters already working in the field, and to a significant extent, interpreters that had some experience interpreting in mental health settings. Those programs that indicated they permitted novice interpreters to enroll in their education and training reported less satisfactory outcomes on the part of these inexperienced participants. In fact, two programs identified that having novice interpreters enrolled in their program ultimately detracted from being able to spend the time necessary with the more experienced program participants. Further, having novice participants required two levels of instruction and was a deterrent from accomplishing the educational goals of the session, particularly with regard to discussions and debriefings centered on case studies and interpreting experiences.

In addition, three of the programs interviewed had designed their education and training programs to include both working interpreters and working mental health providers. These programs felt involving both types of professionals in the training greatly assisted in addressing the issues that arose between the two professions when working together in the mental health setting, and helped to establish a common ground and imparting techniques for building the interpreter/provider understanding and relationship. Those programs indicated that participation of both professional groups contributed to positive program outcomes; however this assumption appears to be largely anecdotal.

Finding 5 – Mental Health Culture and Settings

Each of the programs interviewed spent some portion of time educating participants about mental health culture and the array of mental health settings interpreters may find themselves working in. About half of the programs provided general awareness regarding mental health culture and the range of mental health sub-settings, including geriatric, family counseling, group sessions, substance abuse, trauma, crisis intervention, in-patient versus out-patient, residential treatment, substance abuse, rehabilitation, etc.

Other programs appeared to spend significantly more time on the topic of mental health culture and settings. A few included requirements for participants to complete practicum hours across a number of mental health sub-settings, and/or opportunities for participants to observe treatment scenarios across a range of mental health settings involving Deaf mental health patients and providers. These programs also included additional, highly specific, educational components, such as understanding the role and function of the various members of the mental health provider team, from therapist to technician, and information related to the use of standard mental health testing and assessment tools, and the challenges encountered when these tools are used with Deaf mental health patients.

Finding 6 – The DSM and Mental Health Diagnosis and Treatment

Information related to the Diagnostic Statistical Manual (DSM) and mental health diagnoses and treatment were covered by all of the programs participating in the sessions, however to greatly varying degrees. About half of the programs placed heavy emphasis on imparting a comprehensive understanding of the DSM and mental health terminology; diagnoses and diagnostic assessments; therapeutic approaches, and a range of treatment scenarios and protocols. Those programs were of the mindset that if the interpreter did not have an in-depth understanding of different diagnoses and therapeutic approaches, they would never truly grasp and understand the intention of the session, and subsequently would not be effective working in the mental health setting. In fact, they could actually be a detriment to the attainment of the therapeutic goals for the Deaf patient. To that end, their programs were designed with the goal of providing participants with a sound framework for understanding and participating in the type of discourse that occurs in relation to mental health diagnosis and treatment. For example, significant attention was paid to specific psychological disorders and their implications with regard to communication and interpreting.

Other programs focused on imparting a more general awareness or introduction to the DSM and mental health diagnoses and treatment. Two of the interviewees actually cautioned against spending too much time on the DSM and mental health diagnoses and treatment scenarios, noting it is important that interpreters understand what the DSM is, and how to access it as a resource, but stressing it was not their program’s goal to prepare the interpreter to function as a mental health clinician or therapist.

All interviewees placed importance on the unique type of partnership, or rapport, established between the interpreter working in the mental health settings and the mental health provider. It was repeatedly stressed that in no other setting was this type of relationship building so critical than the mental health setting. The prevailing view was that the interpreter must work as part of the provider treatment team, not simply as the voice or advocate of the Deaf patient, and that to be successful, the interpreter must meet the needs of the mental health provider as well as the mental health patient.

More than half of the interviewees indicated they spent a significant portion of their training and education on the topic of interpreter/provider communication and partnership. Those programs explored and discussed provider goals for various patients, settings and sub-settings, and provided tools and techniques for building effective communication between the two professions, for example, pre- and post-assessment sessions in which the interpreter observes, and to a degree, participates in provider diagnosis and treatment discussions. The objective was to give the interpreter insight and tools they can utilize to understand the goals of the mental health provider and how to pursue those goals effectively. To that end, a great deal of focus was placed on the interpreter’s potential impact on the therapeutic process, provider/patient relationship, and overall session outcome. Overall, the interviewees agreed that the provider must maintain the dominant relationship with the patient, and cautioned that if the patient comes to rely on the interpreter more than the provider, it can adversely affect the therapeutic outcome of the session.

Several of the programs offered student participants opportunities to be involved in mental health provider/clinician meetings. They considered this an important aspect of the education as it allowed the interpreter to better understand provider ‘thought worlds’ and the rationale and science behind the diagnosis and planned treatment of the patient. Several interviewees also stressed that education and training must address the needs of the mental health provider with regard to understanding deafness and the role and responsibilities of the interpreter. Those programs believed the interpreter should be prepared and equipped to initiate discussion and provide information on research and resources to the clinician inexperienced with deafness; this was also recognized as an often uncomfortable role for the interpreter.

In spite of the agreed upon importance of the interpreter/provider relationship, several interviewees, including those that has committed to involving mental health providers in program and curriculum design, reported they have encountered resistance on the part of mental health providers regarding the role and responsibilities of the interpreter, and have not always been successful in bringing the two professions together. They have found that some clinicians, hearing and Deaf, were so accustomed to working alone with the patient, that they were uncomfortable bringing a third person into the intimacy of the diagnosis and treatment session.

When asked to recommend optimal components of training and education for mental health interpreting, all eight interviewees recommended substantial time be allocated to address issues related to building interpreter/provider rapport and understanding.

Finding 8 – Provider/Patient/Interpreter Triad

Several interviewees raised the issue of education and training related to the provider/patient/interpreter triadic relationship. They believed the interpreter needs to have a relationship with the provider and the patient, but must also understand boundary setting and how to establish the appropriate professional distance, especially from the patient, who might tend to bond with the interpreter because of cultural bonding factors. Interviewees also stressed that the interpreter needs to understand the role of the mental health provider, and the importance of supporting the rapport and relationship between provider and patient. The interpreter needs to understand the complexities of the provider/patient relationship, including the interpersonal communication between the patient and the provider and the interpreter’s role in managing that communication and relationship, which is largely psychological and nuanced from person-to-person and case-to-case. For example, the interpreter must understand issues related to transference and counter transference and how it affects interpretation; opportunities for consecutive interpreting versus simultaneous interpreting, or how specific linguistic choices might trigger reactions from the patient and the provider and affect participant reactions. The key objective to be achieved through education and training on this topic was to impart to the interpreter that when interpreting in mental health settings, they must ally themselves with the treatment process, not the Deaf client, which, again, is a different mindset than interpreting in other settings.

Finding 9 – Practicum Experience

Most interviewees stressed the importance of including a practicum component as part of education and training for interpreting in mental health settings. Approximately half of the programs included some aspect of a practicum; those that did not indicated if time and resources permitted, their program would include a practicum component. The programs that included a practicum component varied with regard to how that aspect of education was carried out. In two of the programs, students were provided opportunities for supervised practical application of previously studied theory and content material (based on the Dean Observation/Supervision approach). Another program required a 40 hour individualized practicum and completion of a comprehensive written exam based on the practicum experience to receive state certification. In that practicum, the participant was required to work with a mentor who met state and training program criteria; spend one week at the affiliated state psychiatric unit as part of an observation and supervision experience, and complete practicum hours across a range of mental health sub-settings, for example, outpatient therapy, day treatment, rehabilitation, or group home settings.

Several challenges were raised with regard to offering a practicum. One related to the availability of qualified mental health interpreter mentors or supervisors to oversee participants enrolled in the practicum. Another challenge raised by a few interviewees was access to the mental health settings and actual therapeutic sessions. This access could be problematic due to the intimacy of the setting and patient confidentiality issues. In addition, mental health administrators were often not very accessible or amenable to having an extra individual trailing the patient and provider.

Finding 10 – Observation-Supervision Approach

Each of the interviewees was aware of the Dean/Pollard Observation-Supervision approach. All interviewees viewed the approach as innovative and effective. Four of the program interviewees (including Dean) described their programs as including a substantive observation and supervision component, either strictly or loosely based on the Dean/Pollard project. In those programs the sequence of activities was basically the same. Participants were provided opportunities to observe mental health providers working with Deaf patients; observations of those sessions were recorded and used as the basis for follow-up discussions and debriefings with qualified and experienced supervisors and/or experienced mental health interpreter mentors. Two programs (including Dean’s) used the Demand-Control (DC) Schema as the basis for recording observations; the other programs used different tools and/or checklists. During the supervision sessions, the supervisor, or instructor, reviewed participant observations and led discussions related to those observations with the purpose of analyzing the consequences of the translation and behavioral decisions that might apply to an array of hypothetical Deaf consumers, in the context of the actual observation of hearing clinicians and hearing patients. The objective of all four programs was to emphasize the interpreter/provider relationship, and offer opportunities for interpreting practice and debriefing discussions focused on interpreting options and consequences, including how boundaries were set and how roles played out. The approach provided participants with a better understanding and insight to the goals, thought processes and treatment challenges that clinicians face.

Two additional programs offered participants less formalized opportunities for observing interactions in mental health settings and then discussing and debating what was observed. One was delivered through videotaped sessions of simulated provider/patient sessions followed by classroom discussion led by an experienced mental health interpreter/instructor. The other program included a role play component in which participants were assigned role of provider, interpreter or patient in a simulated therapy session. The role play was followed by breakout group sessions in which participants discussed their role and the behaviors and choices that were made during the simulation, and how choices made might affect the therapeutic outcome of a session.

Finding 11 – Interpreter Protection and Personal Growth

Most of the interviewees indicated that education and training for interpreting in mental health settings should be designed to assist the interpreter in understanding themselves, boundaries and sensitivities, and developing a mature, safety-first approach to interpreting in this complex, often highly-charged setting. Approximately half of the programs included some level of instruction in this regard. They noted that therapists and psychologists received this type of training, but it was typically unavailable to interpreters working in the setting. The interpreter serves as the voice for the patient, which in this setting can be an emotionally devastating position to be in. In this setting, interpreters need to be able to maintain professional distance and not internalize information; they need approaches for managing transference and counter transference, and they need education and techniques that allow them to work in the setting, process information, and then let it go. To that end, the purpose of this aspect of the educational process was to provide individuals working in the setting with avenues for discharging emotional intensity, and with strategies for self-awareness and self-care, or tools and techniques for ‘staying safe.’

Two programs recommended that interpreters that have actually once been a patient in a mental health setting would have an advantage interpreting in this setting. One program recommended that interpreters work with a therapist or coach to increase self-awareness and psychological mindedness, thereby helping prepare them for interpreting in mental health settings.

Finding 12 – Mentoring and Field Supervision

Because of the inherent uniqueness associated with interpreting in mental health settings (and each of the various sub-settings), there will always be situations arising that are new to the interpreter and which pose an array of complexities and challenges. Several interviewees stressed the need to provide those interpreters working in mental health settings with access to ongoing supervision and/or mentoring support. There are many gray areas associated with working in this setting where the input, supervision and feedback of an interpreter with substantive experience in mental health environments could serve as a critical sounding board to the working practitioner.

One interviewee had worked with the New Mexico Mentoring Program to design and develop a 16-week on-line mentoring curriculum. The need for the curriculum was driven by the fact that New Mexico is such a large, rural state, and that many of the interpreters working in mental health settings remotely located in the state, with little or no access to experienced supervisors or mental health interpreters. The curriculum was based on a 360 page workbook and delivered through readings in the workbook, on-line research activities and email communication with an assigned mentor. Each chapter of the workbook included readings and self-awareness activities designed to simultaneously expose interpreters to typical activities they might interpret in psychiatric settings and increase self-awareness. There were also on-going assignments and weekly activities to send to the mentor. About one third of the curriculum focused on mental health and mental illness. The second portion of the training focused on emotional nuance, considered a critical part of the training experience. The third portion of the curriculum simulated activities to practice incorporating emotional nuances into voicing and signing.

Another program assigned a mentor to program participants required to complete a comprehensive practicum to achieve state certification. The mentors had to also meet state and training program criteria. That program reported one of its challenges had been finding qualified mentors to serve in this capacity.

Mental Health Interpreter Education and Training Delivery Modes

Finding 13 – Classroom Instruction

All of the programs interviewed included a component of classroom time. For some programs, that time was used to cover content information, such as the DSM and mental health diagnosis and treatment. Other programs stressed that training and education for work in this setting must include interactive opportunities for participants to discuss and debate choices, options and consequences with other participants under the guidance of experienced instructors – typically in a classroom setting. The four programs that implemented some aspect of the Dean/Pollard Observation–Supervision approach used the classroom setting as the forum for discussing and debriefing participants on the observation portion of the program. When asked to recommend optimal delivery mechanisms, nearly all interviewees indicated that some aspect of interactive classroom discussion and debriefing was necessary. Two programs actually cautioned against education and training that did not include some component of interactive classroom time.

Finding 14 – On-line Opportunities

Several interviewees identified on-line components of their program. These components varied widely and include: reading and research assignments to participants wherein they must use the internet to access the DSM or other relevant resource materials; interactive discussion forums; listservs among program participants, and e-mail to communicate and exchange information with an assigned mentor. However, for the most part, interviewees cautioned against on-line delivery for all aspects of education and training for interpreting in the mental health setting. As noted above, interactive classroom-based discussion and debate were considered by most a critical component of education and training for interpreting in this setting.

Finding 15 – DVDs and Videotapes

Many of the programs interviewed used DVDs or videos to support the instruction process. Those described by participants include:

Videotape of a simulated, one-hour counseling session involving an interpreter, an experienced therapist and a volunteer Deaf patient. Program participants observed and discussed the session.

A videotape that captures “Interviews with Therapists,” and portrays seven therapists expressing their interest in working more closely with the interpreter and their need to understand more about Deaf culture. It is intended to help convince the interpreters that therapists want this communication and relationship with the interpreter.

Videotape of a Deaf consumer. Participants are charged with stopping the videotape at various points and providing interpretation. They also are required to tape themselves as they are watching the videotape to understand how their reactions manifest themselves on their face.

Treehouse Productions Video, organized around seven separate vignettes, each presented by professional actors. The vignettes portray various scenarios related to interpreting in mental health settings, each of which is designed to highlight a number of issues that might arise in the mental health setting.

Videotaped sessions between the mental health provider, experienced interpreter and Deaf patient. The tapes to stimulate discussion and debate in the classroom with program participants, who include working interpreters and working mental health providers.

A DVD of a number of different Deaf, mental health patients during diagnoses and treatment sessions.

Section II – Interview Summaries

Individuals selected to participate in the interview sessions were identified by the NCIEC Mental Health Interpreting work team. An information interview guide was developed by the external consultant with input and final approval of the NCIEC work team leader. The eight individuals participating in the interviews were:

Interviewee: Izabel Arocha

The lecture series and certificate program evolved as a result of hospitals in the state expressing frustration with the availability and preparedness of mental health interpreters. Mental health providers from the Division of Mental Health at Cambridge raised the need and actively participated in the course curriculum development. It has not been hard to attract interpreters to either the course or lecture series because they already recognize they need specialized training to succeed as interpreters in mental health settings.

The Cambridge Health Alliance Mental Health Lecture Series for Medical Interpreters is carried out over a 10 week period – one evening a week for 3 ½ hours per evening. Most program participants are local, have a medical interpreting background; some had a mental health interpreting background.

The Cambridge College Mental Health Interpreting Certificate Program is a two course, six credit program, offered to graduates of the Medical Interpreting Training Program and/or to interpreters who are currently in professional practice. It is geared toward working interpreters; the majority of the class was comprised of spoken language interpreters. Participant prerequisites are documentation that the individual has been trained as a medical interpreter, or completed a comparable program. It is strongly recommended that interpreters seeking to take the course have at least two years of experience, but this has not been strictly followed. It has been learned that this prerequisite should be enforced as program outcomes have not been as successful for novice interpreters that have completed the course. For example, novice interpreters may have passed the written test and interpreting skills portion of the program. Where they are not as strong is in the case discussions, as they have no cases to bring forth, and cannot compare physical to mental encounters if they do not have this previous interpreting experience.

The program is delivered through classroom instruction with follow-up homework assignments. The overarching objective is to teach students how to meet the needs of both mental health patients and providers by becoming fluent in English, mental health terminology, and one other language. Students become familiar with the Diagnostic Statistical Manual (DSM), frequent and less common mental health diagnoses and treatment options, frequently prescribed psycho-pharmaceuticals, and appropriate modes of interpreting for the mental health patient. Both consecutive and simultaneous interpreting are addressed as well as clarification of the role of the mental health interpreter.

The first portion of the program places emphasis on the issue of vocabulary and understanding of the DSM. Participants have to present on different diagnoses and demonstrate what they have learned with regard to mental health discourse. They are assessed on the type of vocabulary and thinking they used during their discourse/presentation, including how they described patient demographics and secondary symptoms. The objective is to teach participants how to speak the way providers speak in this setting and become comfortable with mental health provider discourse. They are tested on vocabulary as well as understanding of subject matter. The second portion of the program focuses on interpreting in mental health settings. The goal is to teach participants that mental health settings are unique, and to be successful interpreting in these settings, the interpreter must learn how to integrate themselves into the mental health culture. Participants must also understand that mental health is more than just one setting. For example, in Arocha’s institution, there are nine different mental health divisions including geriatric, adolescent, substance abuse, family counseling, outpatient, lockdown, etc. Each setting is unique and presents its own set of issues and challenges. The interpreter needs to understand each of the various sub-settings and the issues and interactions that might arise in each (for example, family meetings, use of patient restraints, safety issues, etc.). The interpreter also needs to understand their unique role in the mental health setting – that they are a team member with the mental health providers – not an outsider. This is a complex issue – that the interpreter is part of the treatment team and not the patient advocate. To that end, the course is designed to provide participants with a good understanding of mental health culture and a framework for understanding and participating in the type of discourse that occurs related to diagnosis and treatment, etc. The interpreter needs to understand the provider/patient relationship and have the necessary skills to understand issues of transference going on between the two and how to interpret communication appropriately. Arocha referred to the Dean/Pollard DC schema and the need for the interpreter to understand there is much more going on in a mental health setting that affects communication than in other settings, including medical settings.

The third component of the program assists participants in putting what they have learned into practice. This portion of the program includes opportunities for role play and debriefing, which helps participants internalize and vocalize some of the difficulties they can expect to encounter working in the mental health setting.

Challenges

It has been difficult to strike the right balance between course objectives, namely, learning about the DSM and the different diagnoses; understanding the unique challenges related to working in a mental health setting, including the dynamic between the patient and provider, and putting what is learned in each of the above two into practice. Because of the large amount of material that gets covered in the first two categories of instruction, the practice aspect is largely sacrificed, yet is considered a critical part of the learning experience.

They could not have a practicum as part of the course; it would have been too hard to have a fourth party trailing the provider and consumer because of the intimacy of the setting and therapeutic process. However, because of the uniqueness of the setting, the practicum is particularly important. They have not really been able to solve this issue, other then to informally support mentoring in their institution so that the interpreter/participant has the opportunity to debrief and receive feedback from an experienced mental health interpreter.

The course did attract some novice participants, who lacking prior experience working in either medical or mental health settings, were not as successful in the program as participants with that experience. They did not collect this information – but sense this to be true. Having both types of participants enrolled in the program was not optimal – each took time away from the other. For example, novice interpreters were not able to effectively contribute to case-studies or rich discussions about actual patient-provider-interpreter triadic relationship building.

Because the program is tied to an educational institution, they are required to follow certain delivery guidelines – hence the night classroom structure. However, Arocha believes it would be optimal to offer the program through a combination of classroom instruction and fieldwork. The difficulty is that mental health settings in the field are often not very accessible or amenable to having an extra individual trailing the patient and provider. While the program offers opportunity for role playing, Arocha believes it is not as beneficial as viewing real patients and providers discoursing in the field would be.

Recommended Components of Training and Education

The Cambridge program incorporated aspects of all three of its course objectives into every classroom session: 1) understanding the DSM and different mental health diagnoses; 2) interpreting in mental health settings and sub-settings and the relationship between the provider, patient and the interpreter, and 3) practicing what was learned in the other two. Arocha believes this has been an effective way of delivering the material.

Arocha identified the Dean/Pollard Observation – Supervision approach as beneficial in the way it matches mental health interpreter students with the mental health provider. She suggests that an optimal part of any training and education for work in this setting should emphasize the interpreter/provider relationship and offer numerous opportunities for practice and debriefing. For example, it should cover how boundaries were set, how roles played out, and offer opportunities for both the interpreter participant, interpreter instructor and the mental health provider to debrief, identify options, and discuss the various consequences of those options.

While the practice in a real-life mental health setting is optimal, it needs to be done carefully. There needs to be a clear understanding of roles between the provider and the interpreter so that the patient does not end up looking to the interpreter as a provider. The provider needs to maintain the dominant relationship with the patient. If the patient comes to rely on the interpreter more than the provider it can set back the entire therapeutic outcome. The interpreter needs to have a relationship with the provider and the patient, but also understand boundary setting and how to establish the appropriate professional distance, especially from the patient, who tends to bond with the interpreter because of cultural bonding factors.

Development of training and education for interpreting in this setting should seek to involve mental health providers in curriculum development. At Cambridge, the psychology director and psychology residents alike were extremely cooperative and excited about developing the curriculum. They were as interested in learning about the interpreter perspective as the interpreters were to learn about the clinician’s perspective. In fact, at Cambridge, the psychology director expressed interest in co-teaching the course (this has not happened).

Learning about the DSM and different mental health diagnoses is critical. The goal is not to memorize the entire manual, but to be familiar enough with it that the interpreter can turn to it as a resource, and can understand the discourse that occurs on the part of the provider with regard to diagnoses and treatment. Possibly aspects of the DSM could be taught on-line. The student participants might be assigned particular excerpts of the manual and then practice discourse related to that excerpt in the classroom.

Arocha cautions against an entirely on-line curriculum. Feels there are aspects that can be delivered remotely, for example the DSM and information regarding mental health settings and sub-settings. However, Arocha maintains the dynamic role playing, feedback and debriefing should be done in a classroom and involve to the extent possible providers and experienced interpreters who have worked in the setting.

Training and education should include an overview/introduction to some of the basic documentation requirements of some of the major regulatory bodies, like the joint commission. This is important information to know when the provider is documenting ‘language access’ in the patient record.

Interviewee: Robyn Dean

Demand-Control Schema for Interpreting Work
Observation-Supervision in Mental Health InterpreterTraining

Prior to the interview, Dean provided the consultant with a number of background materials on the Demand-Control Schema and Observation-Supervision methodologies. These materials served as the springboard for the interview discussions. In fact, they were referred to throughout the interview process. Because of the complexity and level of detail associated with the Dean approach and project, rather than re-characterize the interview notes to create yet another version of descriptions of both, the formal published descriptions of the Demand-Control Schema for Interpreting Work, and the Interpreter Training Project (which is centered on testing the Observation-Supervision approach), are provided below. Following those two descriptions is a section entitled Interview Notes, in which the consultant recorded other information that was obtained during the interview with Dean.

The description of the Demand-Control Schema for Interpreting Work provided below was pulled verbatim from the University of Rochester, Deaf Wellness Center website.

Dean and Pollard (2001) adapted the D-C concept from occupational research conducted by Robert Karasek (1979) and Törres Theorell (Karasek & Theorell, 1990). Karasek and Theorell recognized that occupational stress and illness, or work satisfaction and effectiveness, arise from an interactive dynamic between the challenges ( demands ) presented by work tasks in relation to the resources (controls or decision latitude ) that workers bring to bear in response to job demands. This interactive view of work challenges and worker resources was a rejection of more static views of occupational stress as a function of specific job types. For example, while the occupations of firefighter, teacher, or physician are commonly viewed as high-stress, occupational research such as Karasek’s documented that such professions were not associated with high rates of stress-related illness if workers had adequate resources (e.g., education, experience, equipment and materials, emotional support, and flexibility in decision-making) to perform well in light of job demands. In contrast, when workers were least able to respond to high-demand job situations, (i.e., when they had few controls), stress-related illnesses were at their highest levels.

Dean and Pollard (2001) used the framework of D-C theory to examine the nature of demands and controls in the interpreting profession specifically. They defined four categories of job demands that act upon interpreters: environmental demands, interpersonal demands, paralinguistic demands (formally referred to as linguistic demands), and intrapersonal demands. Environmental demands are interpreting challenges or success requirements that pertain to the assignment setting (e.g., the need to understand consumers’ occupational roles and specialized terminology specific to a given setting or tolerance of space limitations, odors, extreme temperatures, or adverse weather). Interpersonal demands are interpreting challenges or success requirements that pertain to the interaction of the consumers (e.g., the need to understand and mediate cultural differences, power differences and dynamics, differences in fund of information (Pollard, 1998), or the unique perceptions, preconceptions, and interactional goals of the consumers.) Paralinguistic demands are interpreting challenges or success requirements that pertain to overt aspects of the expressive communication of Deaf and hearing consumers, i.e., the clarity of the –raw material” the interpreter sees and hears. Examples of paralinguistic demands are when a hearing individual has a heavy accent or is mumbling or when a Deaf individual is signing lazily, lying down, or has an object in his or her hands. Finally, intrapersonal demands are interpreting challenges or success requirements that pertain to the internal physiological or psychological state of the interpreter (e.g., the need to tolerate hunger, pain, fatigue, or distracting thoughts or feelings.)

In Dean and Pollard’s D-C schema, controls are skills, decisions, or other resources that an interpreter may bring to bear in response to the demands presented by a given work assignment. Controls for interpreters may include education, experience, preparation for an assignment, behavioral actions or interventions, particular translation decisions, (e.g., specific word or sign choices or explanatory comments to consumers), encouraging –self-talk,” or the simple yet powerful act of consciously acknowledging the presence and significance of a given demand and the impact it is having on an interpreting assignment. As adapted from Karasek’s D-C theory, the term controls refers to a broad array of worker characteristics, abilities, judgments, and actions that contribute to effective work. As we use the term, it is a noun, not a verb, and is preferably stated as control options. The term does not refer to –taking control,” –having control,” or “being in control” over demands that may arise. Control options may or may not be effective in meeting demands À in fact, the analysis of the effectiveness and consequences of how one chooses to respond (or not respond) to a given demand is the fundamental manner in which the D-C schema is applied during teaching, supervision, or self-analysis of interpreting work. Dean and Pollard define three temporal opportunities where controls may be employed: pre-assignment controls (e.g., education, language fluency, and assignment preparation), assignment controls (i.e., behavioral and translation decisions made during the assignment itself), and post-assignment controls (e.g., follow-up behaviors and continuing education). When engaging in a D-C work analysis, recognition of a given demand sparks consideration and critique of control options that might be employed during each of these three time periods.

The description of the Interpreter Training Project provided below was pulled verbatim from the University of Rochester, Deaf Wellness Center website.

The goal of the interpreter training project is to refine and evaluate the impact of an innovative training approach that will enhance the work effectiveness of mental health interpreters, thereby fostering more equitable outcomes in mental health care for Deaf and Deaf-blind consumers. An Objective Structured Clinical Exam (OSCE), a contextualized means of evaluating the performance and judgment skills of practice professionals, will also be refined and produced. The project will be led by co-investigator and project coordinator, Robyn Dean, CI/CT. The project methodology will be grounded in Dean and Pollard’s (2001) demand-control (D-C) schema for interpreting work and will incorporate the experience of the nations’ leading experts in the mental health interpreting field.

Our training program and OSCE development will spring from the successful methods already developed through our project Reforming Interpreter Education: A Practice-Profession Approach (Pollard & Dean, 2001), sponsored by the US Department of Education’s Fund for the Improvement of Post-Secondary Education (FIPSE) and conducted in collaboration with the University of Tennessee (see sunsite.utk.edu/cod/fipsedc). That project first immerses students in the D-C schema for interpreting work (Dean & Pollard, 2001). Subsequently, in courses on medical interpreting, post-secondary interpreting, and field work supervision, students engage in a process of D-C-based observations and supervision that is proving highly effective in accelerating student learning about translation and behavioral decisions – comparable to interpreters who have honed their skills over years of professional practice (Davis & Griffin, 2002; Dean, Davis, Dostal-Barnett, Graham, Hammond & Hinchey, in press).

In our FIPSE project, interpreter trainees first learn the D-C schema and then apply it through in-vivo observation activities in practice settings where there is no Deaf consumer or interpreter present , including a variety of medical settings and post-secondary educational environments. Unencumbered by interpreting responsibilities or blinded by a singular focus on sign vocabulary, this observation approach fosters student’s understanding of interpreting work factors that lie outside the strict bounds of language and culture. Often, it is these non-language, non-cultural factors that most influence translation and ethical decisions.

These additional factors exist in every interpreting work setting; they are what Dean and Pollard (2001) refer to as demands (in accordance with Karasek’s (1979) demand-control theory of occupational health and work effectiveness) . In order for interpreters to be effective in their work, the entire spectrum of assignment demands must be understood. Dean and Pollard identify four demand categories in interpreting work: environmental, interpersonal, paralinguistic, and intrapersonal demands. They also identify three opportunities to respond to work demands ² before, during, and after the assignment ² whether those responses include skills development, assignment preparation, specific translation decisions, attitude responses, or behavioral actions.

In our FIPSE project, students bring D-C-structured observation notes into 1:1 supervision sessions with experienced interpreter mentors. Group supervision (i.e., mentor-guided peer supervision) is also employed. In supervision, the language and cultural factors that were purposefully “removed” from the observation experiences are brought forward and interwoven with the environmental, interpersonal, paralinguistic, and intrapersonal demands the student has recorded, through discussions of hypothetical Deaf or Deafblind consumers who might have been in that situation. Discussions of interpreting for consumers are thus embedded in the students’ more thorough appreciation of the nature of the observed work settings and the typical goals and processes of hearing consumer dialogues and interactions in those settings. This fosters a greater comprehension of communication (and service) equity when considering the presence of Deaf, hard-of-hearing, or Deafblind consumers in such settings. It also allows considerations of multiple, alternative translation and behavioral decision with various types of consumers, which leads to broader, more generalizable learning. This contextualized approach to interpreter training is consistent with contemporary training methods in other practice professions, such as problem-based learning (PBL) in medical education (Frost, 1996.)

There are other benefits to this observation/supervision training approach. In our FIPSE project, students are developing comfort and enhanced professional and consumer respect in the presence of discussions of patients’ personal medical histories and physical examinations and procedures. They also are privy to the unique perspectives, communication goals, frustrations, practice challenges, ethical dilemmas, etc., of physicians. These insights foster the interpreters’ experience of themselves as fellow practice professionals. And through their application of the D-C schema to interpreting work, they see how their translation and behavioral decisions ² like physicians’ decisions ² are responses to complex demands of the job and, in turn, have a complex spectrum of consequences. Through the supervisory process, their dialogues with mentors and colleagues help them to assess, learn from, and refine those decisions ² again, just like all practice professionals do (Dean, et al., in press).

The proposed interpreter training project will begin with a meeting in Rochester, NY where four national experts will join Ms. Dean and Dr. Pollard to discuss and refine the proposed training methods, content, and research plan. Of the experts under consideration, most have already taken D-C schema workshops from Dean and Pollard and have begun incorporating its philosophies and methods in their interpreting work and teaching. After the panel’s consensus opinions have been incorporated into the research plan, the training project will be conducted in four urban settings with sizable Deaf populations as well as significant ethnic and language diversity within the local Deaf population: Rochester, NY (year 1), Minneapolis (year 1), New York City (year 2) and San Francisco (year 2). An expert interpreter mentor in each collaborating city has agreed to participate in the project: Mark Allan English in Minneapolis, Dan Veltri in San Francisco, and Jody Gill in New York City.

In each location, the project will span 5 months. Phase one involves D-C training for the expert mentor and any local collaborators, provided by Ms. Dean. This training will ensure that the collaborators have a thorough understanding of the schema and how it is specifically applied to the observation and supervision components of the trainees’ experience. Phase two involves the recruiting and training of a pool of 10 certified interpreters per site (see details below). Phase three involves the administration of an OSCE (described below), designed by the project team and adapted to the local circumstances of the prior training, to the 10 interpreter participants and a sample of 10 local interpreters who did not receive the D-C schema training. Subsequently and for the remainder of the project period, we will be tracking a number of post-training measures (see below).

The method of interpreter training used will parallel the observation/supervision approach described above and successfully employed during our FIPSE project. In this case, however, the observation environments will be a variety of mental health service settings. Only interpreters certified at the C.I./C.T. or C.S.C. levels by the RID or levels 3 ²5 by the NAD will be enrolled in the study. In each participating city, the expert mentors named above will be responsible for arranging site observations for their participants, utilizing their local contacts and resources. Each interpreter participant will complete 30 hours of observations over the course of 4 months in a variety of settings (inpatient, outpatient, emergency department, chemical dependency groups, etc.). To aid in their observation work, participants will use D-C observation sheets (modeled after those being used in our FIPSE project) that help them identify the salient issues in each situation and prepare for their later supervision sessions.

These interactions with mental health professionals in their work environment and “behind the scenes” – including the dialogues that will invariably occur between “patient events” – will yield important learning and professional development benefits for these interpreters, judging from similar results emerging from our FIPSE project. The interpreters will gain a much greater appreciation for the goals, thought processes, and treatment challenges that clinicians face. They will develop, and reflect back to the clinician, a greater appreciation for their own role as a fellow practice professional seeking a similar, collaborative goal of optimal patient care. These relationship benefits are fostered because the observing interpreter is not “in role” or consumed with a singular focus on language and sign choices and because the clinician, in this case, is not a consumer of interpreting services but a fellow practice professional.

While accruing these 30 hours of observations, participants will attend 2-hour group supervision sessions each week, led by the local expert mentor and attended by the other participants in the research cohort. Participants will receive continuing education units from the RID’s Certification Maintenance Program. Each of the expert mentors have been involved in mental health interpreter training on a national level. The content of these 2-hour supervision discussions will be driven by the events and issues described on the students’ D-C observation sheets but also informed and guided by the expert mentor’s own knowledge, pedagogical priorities in mental health interpreting, and teaching style. This approach is more effective than a proscriptive curriculum that a teacher is forced to adhere to and teach in a vacuum. As in PBL, our approach allows the contextualized nature of the problems confronted by the students (their identification of work demands in the four categories defined by Dean and Pollard) and the ensuing discussion of the hypothetical presence of Deaf, hard-of-hearing, and Deafblind consumers, to draw upon the mentor’s (and student peers’) knowledge and experiential resources in ways that non-contextualized, rote learning is unable to do effectively (including the typical mental health interpreting training modality of lectures or workshops.) The content that these expert mentors’ have previously discussed in lectures, workshops, and publications (e.g., Stansfield & Veltri, 1987; Veltri, 1993, 1997) is quite consistent with one another’s (and with Pollard, 1998b) and the collaborative meeting that takes place at the beginning of this project, and the continued oversight of the training by Ms. Dean, will assure that there is agreement and consistency regarding the major content themes, facts, and issues that we desire to impart over the course of the training period. Supplemented by some required readings, the supervision dialogues will be the primary vehicle through which content information is shared. This will not only contextualize the content, leading to better learning and retention, it will allow for the frequent reinforcing of content and promote generalization of learning as students encounter, identify, and discuss similar mental health issues repeatedly over the course of these 4 months.

Our practice profession approach to interpreter training seeks to enhance translation and behavior judgment, confidence, problem-solving skills, and self-evaluation abilities which cannot readily be assessed with existing language-focused interpreter evaluation tools. Fortunately, improvement in methods for assessing these more elusive but critical professional competencies have paralleled the evolution of PBL in medical schools. Among the more widely used approaches is the OSCE. OSCEs commonly involve simulated practice scenarios where students are evaluated on various performance skills (not just knowledge), including professional reasoning and behavior, which is gleaned from post-encounter interviews with students and trained OSCE actor-participants (Educating Future Physicians for Ontario, 1995). An interpreting-specific OSCE is being developed and piloted as part of our FIPSE project (Pollard & Dean, 2001). It is being designed in collaboration with our URMC faculty colleagues who have considerable experience in this evaluation method. Our OSCE will reflect the broader view of critical interpreter competencies we desire to impart through our D-C approach to interpreter training. Our OSCE is intended to set a precedent for the evaluation of interpreter competencies from a practice-profession perspective. This tool and approach should be of interest to ITPs as well as to states that are pursuing licensing regulations and any entity that employs sign language interpreters and seeks to document their competencies. A joint task force of RID and NAD is currently working toward development of a national interpreter examination to replace the current RID test. Leaders of this task force are in close contact with the DWC, monitoring our progress with the OSCE and our other innovations in interpreter training.

The proposed project will develop and employ an OSCE at each of the four sites conducting our D-C training. Local variations in the OSCE scenarios and content will be based on each locale’s characteristics in terms of Deaf consumers, mental health services available, and the training emphases that emerged over the 4 month training period. The OSCE will consist of practice scenarios that are depicted “live” by teachers and volunteers, on paper, and/or on videotape. Student performance is assessed through eliciting not only specific translation decisions but behavioral decisions (or lack thereof) and the reasoning behind them. Reasoning and actions relating to Dean & Pollard’s (2001) four demand categories and three opportunities to employ controls (pre-assignment, assignment, and post-assignment) also will be evaluated. The opinions of the aforementioned expert panel and the local expert interpreter mentors will determine the nature and range of optimal OSCE responses and scores. Again, a control group consisting of 10 similarly certified interpreters who were not part of the training cohort also will take the OSCE at each training site. (They will receive compensation for their time.) Clinical Research Coordinator and interpreter Susan Chapel will score all OSCEs. She will be unaware of the D-C training status of the participants.

Additional post-training measures will be obtained at 6-month intervals throughout the remainder of the project period. These measures will track the impact of the training on the actual work experiences of the trained interpreter cohort from each of the four training sites. These data will include the interpreters’ assessments of their work competencies, their frequency of use of D-C concepts and practices in their work, their ongoing assessment of the value of the specialized training they received, and the frequency of their work in various mental health service settings. Also, post-training data will be sought from the hearing and Deaf consumers for whom these interpreters work (via a request to participate in the feedback portion of the study that is written on a card the interpreter leaves with consumers; the card will direct consumers to a portion of the study website, where further information can be obtained and feedback questions answered on-line). Consumers will be asked to evaluate various aspects of the quality of the interpreters’ services and behavior as well as the impact that the interpreter’s services had on mental health service access and outcomes for the consumers. Consumers will be asked to complete the Client Satisfaction Questionnaire Mental Health Center (Larson, et al., 1979). These data will be collected and organized via the web-based data analysis application and report interface that will be used for all studies in this project (described in the Plan of Evaluation section of this narrative).

In year 3 of the project, the accumulated data (and experience) from conducting the interpreter training and administering the OSCEs at these four training sites, and tracking interpreter service outcomes subsequent to each site’s training, will be compiled and used to construct a final OSCE and a mental health interpreter training manual for national dissemination. For the final OSCE, we will hire Deaf, hard-of-hearing, Deafblind, and hearing individuals, including those from ethnic and language minority groups, to portray the most useful mental health service scenarios that emerged from conducting OSCEs at the four training sites. These scenarios will be digitally filmed by URMC audio-visual professionals. Other studies in this NIDRR project also employ digital filming to record actual mental health service delivery to Deaf, hard-of-hearing, and Deafblind individuals. These acted and actual film clips will be professionally edited and used to produce the final OSCE and training manual which will include relevant film clips and narration on CD (with open captions). The training manual and OSCE package will be completed in year 3 of this project, though data-tracking of our interpreter cohorts will continue through years 4 and 5.

Dean Interview Notes

Dean views interpreters as ‘practice professionals’ versus technical professionals. This is because the work dynamics and work environment are constantly changing.

The training project was designed for ‘student’ interpreters working in educational and medical settings (most of the participants are actually working interpreters that have returned for more in-depth and specialized education – maybe working toward a BA degree – so they are not purely students), although some are full-time students.

The Observation-Supervision approach is based on concepts of problem based learning (PBL), which is typically used in training medical students. It is based on a student-centered classroom, in which learning takes place in contextualized manner involving actual patient cases.

Participants in the Interpreter Training program must first have completed D-C Schema training.

Dean thinks it is critical to provide interpreter participants enrolled in the interpreter training program with insight into the ‘other side of the story’ – hearing professionals thought worlds. To that end, participants observe in specialized assignment settings with no Deaf consumer or working interpreter present.

Participants observe approximately 15 hours of mental health service provision between hearing clinicians and hearing patients; across variety of MH settings. Participants are also required to observe 1-2 hours in a number of other settings such as acute care, group therapy, family, child adolescent, etc.

Guided by a detailed mental health observation form, program participants document and analyze EIPI elements of observations. Observation forms submitted in advance of supervision sessions to site supervisor. After 8-10 hours of observation completed, supervision sessions begin – observation and supervision sessions overlap for remainder of course. During the supervision sessions, the instructor reviews the completed observation forms and uses them as the basis to facilitate student learning. They are discussed with regard to content and context. Specifically, both the controls that could be employed and the benefits and consequences of the various control options are discussed and debated. The purpose is to draw out and analyze the consequences of the translation and behavioral decisions that might apply to an array of hypothetical Deaf consumers, in the context of the actual observation of hearing clinicians and hearing patients. Testing occurs at the end of the observation-supervision sessions, is conducted through interviews, and is based on content as well as judgments made with regard to translation and behavioral decisions.

The four program instructors participating in the research program were taught to use the dialogue process versus the didactic teaching approach. It is also critical that the instructors of the Observation-Supervision approach be very familiar with the D-C schema as the process by which to make decisions. Instructors received this training prior to instructing in the program. They believe it is critical that the supervisor/instructor is able to effectively cover both the creative aspect of teaching as well as the didactic.

Challenges

Dean/Pollard changed the last two test sites and modified some aspects of the training in order to better determine if it would be successful, effective and transportable across diverse settings.

Dean is aware that a number of IEPs are already teaching the D-C schema as part of the framework for interpreting, including interpreting in mental health settings. However, they do not collect information about these efforts and therefore do not know the extent of these teachings, the quality of the instruction, or the ultimate outcomes.

Dean has collected data on both content acquisition and the interview testing process to judge and test decisions related to translation and behavioral. See Dean’s article included in resource materials list. (Need link)

Recommended Training and Education

Dean recommends that interpreters working in mental health settings have training in the D-C Schema and participate in Observation-Supervision training. She also stresses the PBL approach to learning.

Dean recommends that the NCIEC work team look closely at the Alabama Mental Health Interpreter Training Program and curriculum. She thinks that program has done a very effective job training interpreters to work in mental health settings. That program offers, according to Dean, a ‘full continuum’ of training and practicum experience. Dean indicates that the Alabama program, which results in state certification, is more robust and stringent than national certification requirements.

Interviewee: Charlene Crump

The Mental Health Interpreter Training Program was formed as a result of a federal/state lawsuit (The Bailey Lawsuit and Settlement). The program is unique in that it is housed and administered at the state level versus part of a college or university. Another outcome of the lawsuit was establishment of a Deaf unit as part of the state mental health facility. In addition, the law provided for four regional coordinators, each of which is a qualified Deaf therapist. The regional coordinators are intended to serve the state’s outpatient Deaf population.

The Mental Health Interpreter Training Program is carried out through completion of four major components of training and education. The first is a 40 hour, week-long extensive training session. It is offered once a year for up to 50 participants. At the end of the week, participants receive a certification of completion. This component of the training program is geared primarily toward certified interpreters. However, if there slots vacant, it has been available to interpreters that have not reached certification if they have prior interpreting experience, including interpreting in mental health settings. Some clinicians have also taken the training, as well as individuals working in the field of Deafness, or interested members of the community.

During the weeklong training, participants receive extensive education on mental health settings, the DSM and different mental health diagnoses and treatments. The objective is to ensure participants understand mental health terminology, and how a diagnosis or treatment impacts on how you interpret. As an example, in the case of a hearing clinician working with a Deaf bipolar patient, the clinician may in a very deliberate way ask the patient a very open-ended question, and drop eye contact. This approach has a direct clinical purpose and is intended to elicit a particular response from the patient. However, if the interpreter misinterprets the clinical objective and does not understand the goal of the session, they may actually unintentionally become a barrier to achieving that goal. The training program weighs so heavily on the DSM and understanding mental health that it also offers a separate eight hour workshop on the topic.

Program participants are also introduced to the concepts of Demand Control Schema and Observation and Supervision by Robyn Dean and Bob Pollard, who participate as instructors in the training, including training for program instructors and mentors on the Supervision aspect. These techniques are designed to assist participants to analyze the mental health setting, assess their options and consequences of those options, and establish the necessary boundaries and professional distance. The concepts of both DC and Observation/Supervision are implemented during the second component of the program training.

The second component of the training program is a practicum. Only certified interpreters that have completed the first training component can participate. Participants are required to complete 40 hours of practicum experience over the course of one year. Each practicum is individualized to the participant. The participant is required to work with a mentor who meets state and training program criteria. CEUS through the independent study option are available for the 40 hours of practicum experience. In addition, participants are required to spend one week at the affiliated state psychiatric unit as part of an observation and supervision experience. In line with the Dean/Pollard approach, participants first observe hearing clinicians and patients and then participate in a supervision discussion and debriefing. They then move into settings that include Deaf patients and qualified interpreters, following the same observation/supervision approach. During the practicum, participants might also spend time or be mentored by the regional interpreters or coordinators who work in the community. This might provide them experience regarding outpatient therapy, day treatment, group home settings, etc.

The participants are provided at the outset a checklist of experiences they need to demonstrate through completion of the practicum, some weighed more heavily than others. They receive a score at the completion of the practicum.

Once participants have successfully completed their practicum, they are required to take a comprehensive written exam on best practices taught throughout the program and what was learned from the practicum. The exam is not designed to ask about symptoms, but includes synthesis geared queries related to the demand control considerations an interpreter might want to assess when interpreting for a particular type of patient (i.e. bipolar patient) in a treatment discussion. The test takes from four to eight hours to complete. Once a participant passes that example, they received state certification as a Qualified Mental Health Interpreter.

The fourth component of the training program is ongoing education maintenance. Participants that have achieved state certification as a Qualified Mental Health Interpreter are required to achieve forty hours of active training or interpreting in the setting per year. This requirement can include CEUs related to mental health, actual time interpreting in mental health settings, and/or participation in on-line assignments and discussions offered monthly by the program. The program also offers periodic workshops on various related topics that count for hours in this regard. In addition, they offer online literature reviews focused on mental health, following which the interpreter can participate in online discussions for CEUs.

The program also offers a clinical training component, geared toward clinicians in the state. The objective is to train clinicians and other mental health providers in how to work with Deaf patients and with interpreters. Both hearing and Deaf clinicians have participated in this training. Professionals have come from many other states to participate in this training.

Finally, the program has produced several DVDs. In one DVD, a number of consumers consented to being videotaped during diagnoses and treatment sessions in order to assist in achieving interpreter training goals. The program has also developed a DVD simulating various interpreting situations. That DVD uses actors. Both DVDs are used in the practicum portion of the training program, and often when the program directors make presentations about the program to outside groups, like RID. To date, they have not made either DVD available outside use in their own program.

Challenges

A challenged related to the practicum portion of the training is finding enough qualified mental health mentors to work with the number of participants enrolled in the program.

A lesson learned was that it is difficult, sometimes impossible, to make training components for hearing and Deaf interpreter participants comparable. For example, they tried to utilize existing program simulating visual hallucination for CDI participants to parallel auditory hallucination simulations used for the hearing participants. This turned out to be ineffective and was ultimately dropped from the training. The program came to recognize that there cannot always be the same materials/exercises used when training hearing and Deaf interpreters.

They believe they currently have the right level of qualified trainers and presenters for the current training program. However, they have attempted to develop and offer a second forty hour classroom training component to follow the first, but have not been able to find individuals with the depth and combination of experiences to work as instructors for this envisioned training. They would seek to find individuals that are content experts (the clinical side), as well as experts in Deafness, and interpreting. They have had difficulty locating an individual(s) with all three attributes. Currently, they are working on developing these competencies in-house.

Another challenge is with regard to the clinician and other mental health providers. They have found that some clinicians, hearing and Deaf, are typically put off by the need to involve the interpreter in such an extensive manner. These professionals are used to working alone with the patient, and are uncomfortable bringing a third person into the intimacy of the diagnosis and treatment session.

The other challenge is with regard to the interpreter working in this complex setting. Because of all of the inherent things that can go wrong with interpretation in this setting, it puts extreme pressure on the interpreter to ensure that the interpretation is assisting in meeting the goals of the therapeutic session. When working in this setting, the interpreter needs to ally themselves with the treatment process, not the Deaf client, which is a different mindset than working in other settings.

Recommended Training and Education Components

The interviewee provided the following list of competencies that should be addressed in education and training for interpreting in mental health settings:

Interviewee: Karen Malcolm

Interpreting in Mental Health Settings Workshop

The Interpreting in Mental Health Settings workshop has been offered through the Vancouver Well-Being Program, a government funded program, as well as funded by provincial interpreting associations. Mental health services to Deaf individuals in British Columbia fall under the Well-Being program. The workshop was developed by Karen Malcolm and a therapist as a result of a large scale investigation into the mental health and therapeutic needs of Deaf individuals in British Columbia. A copy of the findings of that study is attached as background to this report (see Appendix D). This workshop is designed for both working interpreters and working therapists as participants. The workshop is offered one weekend each month, and has only been delivered in its entirety one time to date. There have been discussions related to repeating the workshop, but funding is an issue. Karen Malcolm, one of the workshop originators, developed a second workshop designed just for working interpreters. This second workshop has been funded by the provincial interpreting associations. An overview of both workshops is provided below.

Interpreter/Therapist Workshop

This workshop is delivered in a classroom setting. It has two primary components: role play/observation, followed by participant debriefing and discussion. The role play/observation component is based simulation of a one-hour counseling session. Karen Malcolm assumes the role of the interpreter, an experienced therapist serves as the therapist, and a volunteer Deaf consumer that is or has been a client of the Well-being Program plays the part of the patient. The session is based on the real situation of the volunteer consumer. Because this individual is or was an actual patient and is sharing his/her real situation or problem, the individual/situation chosen is typically ‘safe’ and not emotionally charged. The interpreter and therapist workshop participants observe the session, which is captured on videotape.

The classroom debriefing and discussion component of the workshop is based on what occurred and was observed during the counseling session. The workshop participants discuss their observations and reactions to the session. The two role players – the therapist and the interpreter – in turn provide their views about what occurred. The therapist discusses his/her goals and intention of the session, and the interpreter talks about what she thought was happening. The volunteer Deaf consumer also presents their perceptions of what occurred. The debriefing and discussion continues to the next level, during which the videotape of the session is replayed and discussed in more detail. At a certain point, the workshop participants are divided into two groups: therapists and interpreters. The two groups continue to discuss the session from their particular professional perspective.

Interpreter Workshop

This second workshop is designed solely for interpreters and delivered over two full days. There were approximately 20 participants in the session, most of which have some previous mental health interpreting experience. However, a few participants had no previous mental health experience. This stream focuses on the provision of tools for conducting pre- and post-session discussions with the therapist in charge, and approaches to foster participant personal growth.

The goal is to provide interpreter participants with tools for initiating and participating in pre- and post-session discussions with the therapist. Participants are divided into small teams and given role playing cards, and assigned one of three roles: therapist, interpreter, or consumer. The role playing card puts forth a particular scenario. For example, the card might say the therapist is resistant to entering into pre- and post-session discussions with the interpreter. With regard to that scenario, the participant assigned the role of interpreter would be provided tools they might use to describe to the therapist the importance and need for those sessions. This stream also focuses on fostering the personal growth of the participants in areas not related to mental illness, but directed toward providing the participant with tools for keeping their distance and not personalizing the issues discussed. To that end, the workshop provides approaches for transference and counter transference; staying safe in settings that become highly charged or violent; balancing compassion, fatigue and burnout, and setting appropriate boundaries.

Challenges

Therapist participants sometimes struggle with the confidentiality aspect related to the role of the interpreter and having that third person in the room and part of the discussion.

The interpreter-only stream is two days in duration – not long enough to accomplish all that needs to be taught. Because of the limited time available, there is not enough time to touch upon the DSM or specific aspects of mental illness. However, this is considered by the workshop developers to be very important: interpreters need to understand different therapeutic approaches, or they will never truly grasp and understand the intention of the session.

It was also identified that there are many times in mental health settings when consecutive interpreting is more appropriate than simultaneous interpreting. Because the situation is often emotionally charged, and can sometimes involve a spouse or other family members, it often makes more sense to allow the Deaf patient to complete their thought before initiating the interpretation. One issue not adequately addressed by the workshop because of time constraints is provision of decision-making tools to assist the interpreter in determining when to consecutively interpret, and when to take on narrator role.

There are few interpreters currently working in mental health settings in Vancouver, and there is not a lot of funding to provide training to those that are, or expand the number of interpreters that could effectively interpret in this setting.

They do not currently have processes to evaluate changed practices as a result of participation in the workshop sessions, although they do collect session evaluation forms.

Recommended Components of Training and Education

Education about different therapeutic approaches and the DMDR – specifically, what different interventions look like and the reasoning behind them

Understanding of DSM categories and what some of the most prevalent symptoms are

Knowledge of standard psychological tests and issues related to using these tests with Deaf patients

Tools and techniques for forming a working relationship with the therapist, including when to clarify and direct comments back to the therapists

Opportunities for therapists and interpreters to be together in the classroom to discuss situations and perspectives

Role playing, which should be real-time to extent possible

Opportunities to observe therapists working in mental health settings with actual hearing and Deaf patients

Observation/supervision approach has great deal of applicability and validity

Providing practices and tools for interpreters working in highly charged mental health settings that will help them not to personalize the situation and keep the necessary distance

Methods for establishing boundaries for interpreters working in mental health settings (for example, they should not work in other setting with the consumer they are working with in the mental health setting although the consumer will try to obtain their services in other life settings)

Interviewees: Greta Knigga and Barbara Dunaway

Wright State University, School of Professional Psychology
Training Program in Mental Health and Deafness

The Training Program in Mental Health and Deafness is designed for the participation of both mental health professionals and interpreters. It is offered through the School of Professional Psychology (SOPP). The purpose of the program is twofold: to train mental health professionals in working with Deaf clients and interpreters, and to prepare interpreters for work in mental health settings. The training program is multi-disciplinary, involving five programs, two universities and one college. These include: psychology, psychiatry, mental health counseling, rehabilitation counseling, art therapy and interpreting. The primary goal is to train mental health professionals in working with Deaf clients, and to prepare interpreters for work in mental health settings via didactic and clinical experience. Participants completing the 8 month program are provided a certificate.

The SOPP program is designed to provide supervision of clinical work conducted by mental health students, and of interpreter work done by student interpreters, at a week-night clinic and Saturday morning teaching program. The week-night clinic is a three-hour clinic, open Wednesday evenings during the academic school year (October through May), and offering services to Deaf individuals, couples and families as well as hearing partners and family members of Deaf clients. The Deaf patients have agreed in advance to participate in the program, knowing the counseling session is being observed through a glass mirror. Interpreter and mental health students are assigned to work in pairs so that rules of ethical practice, including confidentiality, for both disciplines are observed. Approximately 50% of supervision of both the mental health students and the interpreter students is conducted during the Wednesday night clinic. The remainder of supervision occurs during the Saturday morning teaching program, held every other Saturday, via case presentations and case discussion of previously videotaped therapy sessions.

The Saturday morning teaching program runs over the course of the full eight months. Members of the Mental Health and Deafness Program teaching team meet every other Saturday for an ongoing training series and to continue discussion on current cases seen the previous Wednesday. The first hour involves a lecture presentation by the clinical supervisor and the interpreter supervisor. This lecture covers a wide variety of topics. The second hour involves current case discussions between the interpreter students, clinical students and supervisors. The remaining time involves presentations to the whole group by area presenters or by videotapes as scheduled. Though there is an open door attendance policy to the training series, case consultation occurs only between the teaching team members.

They accept interpreters that are currently working in the field, interpreter practicum students, and psychologists, mental health counselors, as well as students enrolled in study in those fields into the training program. They never separate the two groups (providers and interpreters) and believe very much in the team approach. For example, one session might focus on introduction to mental health, geared toward the interpreter contingent, and the next session might be orientation to Deafness, targeted toward the provider contingent. Students range from age 20 to age 60, and many drive an hour or more to participate in the training.

During the next quarter they will offer for the first time an 11-week, four-credit elective course on interpreting in mental health settings. This course is with the BA Program in Sign Language Interpreting in the College of Education and Human Services; it will be offered as part of a bachelor’s completion program. Participants must have an AA degree and have completed a one year practicum at the school level to be accepted for enrollment. The BA course is designed to provide participants for a ‘taste’ of what is like to work with Deaf patients in a mental health setting. Participants are not expected to exit the program as experts, just be better prepared than before. And while the program does touch upon the DSM and mental health diagnoses, the intent is to create awareness only, and to introduce the participants to the manual the information in it. Students are not expected to understand the DSM; their job is not to diagnose the patient or share the seat with the mental health clinician. As an elective course, it will not be offered every year. The year the program is not offered as an elective, another class called ‘specialized interpreter settings’ will be offered.

Challenges

The BA training program is new, so they are still learning what will work best.

Because Deaf patients participating in the SOPP program’s Wednesday evening clinic know they are being observed as part of a training program, the types of patients that participate are often not the most challenging of cases to observe, or the type of cases the interpreter is most likely to encounter when actually working in the mental health setting.

There are several large associate programs in close proximity. Students that enter their program are often very mixed with regard to education, experience and background. This is particularly true with regard to the BA program.

Right now the BA program is only open to students already enrolled in Wright State University.

They would like to expand the SOPP program state-wide. They are beginning to post lecture materials on-line so that they can have professionals off-site teach. They also have begun to identify clinicians across the state that could do some distance training, especially on Saturdays, to expand enrollment.

Because the current training SOPP program is offered on a certificate basis versus for credit, they have not collected information regarding outcomes and changed practices.

They will administer entrance testing and at the end of the BA program they require a senior project or portfolio, so there will be results available about outcomes of that program.

Recommended Training and Education

Both interviewees agree that the optimal training and education should include both interpreter and mental health provider participants.

Training and education should at a minimum require an observation/supervision component. They believe their Wednesday evening clinic has been extremely effective in that allows participants to observe actual patients demonstrating real mental health issues. In addition, training and education for interpreting in this setting should include significant opportunity for mentoring and practice, including interpreting for actual Deaf patients.

Videos of Deaf mental health patients would be extremely beneficial. In the mental health setting, no two cases are the same, so the more practice and exposure to actual cases the better. The videotapes could include both hearing and Deaf mental health patients displaying a number of symptoms. For example, a videotape that demonstrates with anxiety looks like.

They cover a number of basic topics as part of their training program. Recommend that any education and training include the same. Below is an example schedule for their program’s didactic series:

Interviewee: Arlyn Anderson

Mental Health Interpreting: A Holistic Approach to Effective Practice (3 day workshop)
Is It Me? Building Confidence as a Mental Health Interpreter (3-5 hour workshop)
New Mexico Mentoring Program (16-week on-line curriculum)

Arlyn Anderson has been involved in developing and delivering a number of educational activities focused on interpreting in mental health settings, ranging from a half-day core workshop on the subject, to a three day more intensive workshop, and including development of a 16 week mentoring curriculum.

The three-day workshop, Mental Health Interpreting: A Holistic Approach to Effective Practice, is organized around three primary categories of instruction: 1) understanding mental health settings; 2) establishing emphatic connections to both the therapist and the patient – being effective and supportive but maintaining healthy detachment, and 3) tools and techniques for interpreter self-management, including professional control, setting boundaries and protecting the self (interpreter).

The first category of instruction centers on an introduction to mental health therapy, and covers issues such as psychology, theoretical orientations, including insight oriented therapy, cognitive therapy, family therapy, etc. Interpreters need to recognize there is much more than a ‘conversation’ going on between two people (therapist/patient) in a mental health setting. The workshop explores various therapeutic interventions and modality, the most important being the role of the mental health practitioner and the importance of building and supporting the rapport and relationship between practitioner and patient. This provider/patient relationship opens up a lot of things for the interpreter to understand, including the interpersonal communication between the patient and the provider, and the interpreter’s role in managing that communication and relationship, which is largely psychological and nuanced from person-to-person, case-to-case. The objective is to give the interpreter insight and tools they can utilize to understand the goals of the mental health provider and how to pursue those goals effectively.

The second portion of the workshop goes more in-depth into the role of the interpreter with regard to supporting and working with the therapist, and the importance of establishing that communication and rapport. The objective is to impart to interpreter participants the critical importance of working effectively with the mental health practitioner. It addresses the importance and need for communication with providers before and after (pre- and post-sessions) and during interpreting interactions. This is stressed as a critical part of work in that setting, yet the perception is that few interpreters are doing this. Further, Anderson’s perception is that interpreters are often too intimidated to approach the mental health professional, or may have personalities such that make it difficult to communicate effectively, or even initiate communication. The workshop explores different communication techniques. It includes a video: “Interviews with Therapists.” The video portrays seven therapists expressing their interest in working more closely with the interpreter and their need to understand more about Deaf culture. It is intended to help convince the interpreters that therapists want this communication/relationship with the interpreter.

Anderson also teaches a shorter, core workshop entitled: Is It Me: Building Confidence as a Mental Health Interpreter. This 3-5 hour workshop is designed for sign language interpreters, and has been co-presented with colleague, Gail Nygren. This workshop is targeted to interpreters that are already working in mental health settings. An objective of the workshop is to help interpreters understand role and intentions of the therapists. For example, it explores issues like the type of questions a therapist might pose to a patient in order to lead them into different thought modes. The focus is to establish a sound understanding of the mental health setting and mental health therapy, and to help interpreter participants understand therapy goals, the players, and issues like the difference between psychiatrist, therapist, etc., and the different goals of these professionals.

Anderson has also recently begun presenting her mental health interpreting workshops to spoken language interpreters employed by county and private hospitals in the Twin Cities area. These workshops include the core concepts Anderson feels are central to being “a well-rounded mental health interpreter.” She includes the need to be attentive to provider goals, easy-to-miss therapeutic techniques, e.g. deliberate structuring of verbal interventions, and self-care. She includes experiential exercises designed to increase interpreters’ internal awareness of how unconsciously altering various types of questions can lead a client into or out of an emotional space, thus potentially interfering with provider goals.

Anderson has also recently completed development of a 16-week mentoring curriculum for the New Mexico Mentoring Program on mental health interpreting. The need for this curriculum was driven by the fact that New Mexico is such a large, rural state, and that many of the interpreters working in mental health settings in the state are remotely located and working on their own in a rural environment. The curriculum is based in a 360 page workbook. About one third of the curriculum is focused on mental health and mental illness. The second portion of the training focuses on emotional nuance, which is considered a critical part of the training experience. The third portion of the curriculum simulates activities to practice incorporating emotional nuances into voicing and signing. Currently, many interpreters do not give sufficient attention to the difference, for example, when a patient expresses themselves with mixed feelings, there a number of emotional nuances that are critical to capture for the mental health provider. The training helps interpreters pay attention to emotional nuances and provides opportunities to practice interpretation options. The final portion of the curriculum focuses on working cooperatively and effectively in mental health settings. It provides participants with tools and techniques for approaching mental health providers and other professionals and knowing what to discuss with them. Objectives are to assist the interpreter in understanding themselves, boundaries and sensitivities, and developing a mature, safety-first approach to interpreting in this setting.

Each chapter in the 360 page workbook has readings and self-awareness activities designed to simultaneously expose interpreters to typical activities they might interpret in psychiatric settings and increase self-awareness. There are al so on-going assignments and weekly activities to send to the mentor. The curriculum is delivered through readings in the manual, on-line research activities and email communication with an assigned mentor. The program requires participants to complete about 2-4 hours of work per week, for example, looking up and reporting on a portion of the DSM on line. Over the 16 weeks, participants complete their assignments and submit them to their mentor. An assignment might be to explore the goals of a provider in a particular situation, and how they might utilize something like the DSM. It addresses issues such as variance in the psychological community with regard to how providers view and use the DSM.

As part of the mentoring curriculum, interpreters are also provided a videotape of a Deaf consumer. They are charged with stopping the videotape at various points and providing interpretation. They also are required to tape themselves as they watch the consumer on the video to see how their reactions might manifest themselves on their face as they watch the consumer. This videotape is then submitted to their mentor, who provides a debriefing. An objective of this is to teach techniques for developing professional control: while the interpreter may feel things internally in relation to the situation, they must learn control, and techniques for not expressing them externally. The videotape simulation/practice allows the interpreter to see how their biases and sensitivities might manifest themselves on their face and body, and affect what they communicate in any given therapeutic interaction. Anderson emphasized self-care and self-awareness, and how important it is to develop this, particularly to interpreters that may have never directly been affected or involved in therapy sessions. Participants are also provided the video of the seven therapists (described earlier).

Anderson was also an author of the recently revised Standard Practice Paper on Mental Health Interpreting published by the RID.

Challenges

While it is critical to pay attention to building the interpreter/provider communication and relationship, many interpreters working in mental health settings do not understand the importance or take steps to build this rapport.

Many interpreters working in this setting will have various degrees of self-awareness and psychological mindedness; some may not have ever experienced therapy or been in a therapy session before. This prior experience can be extremely beneficial for interpreters working in the setting, though it is necessary for these interpreters to add the intellectual component to enable strong boundaries and sound practice. In the absence of prior personal experience, it would be beneficial for interpreters planning on working in the setting to work with a life coach or therapist in order to develop self-awareness and self-management techniques.

Recommended Components of Training and Education in this area

It is important to provide interpreters working in this setting with basic counseling skills, and practice in the role of the therapists to assist them in understanding how the therapist thinks and the goals of a particular treatment.

A video of Deaf and hard of hearing patients talking about using interpreters and their experiences with interpreters would be useful.

Education and training for working in mental health settings should include information and activities related to increasing knowledge and awareness of mental health diagnoses, for example, Deaf individuals, or even hearing individuals, with personality disorders. In that situation, an interpreter may get drawn into a client’s expression of symptoms without even realizing it. Education is needed to provide interpreters with heightened awareness of the various types of mental illness: not to stigmatize the disease or the patient, but with the goal of creating interpreter understanding and awareness and to communicate more effectively with providers.

It would be useful to develop a DVD or videotape of Deaf individuals with different, active mental health symptoms, for example, a borderline psychotic patient, so that the interpreter trainee would be able to observe the symptoms first-hand rather than read about them in the DSM. * Alabama may have such a DVD.

Therapist and other mental health provider involvement in the training and education would be extremely beneficial to both the interpreter and the provider.

Some degree of training in prevention of burnout and vicarious trauma would be beneficial. Therapists and psychologists receive this training, but it is typically unavailable to interpreters working in this setting. This kind of training provides individuals working in the setting with avenues for discharging emotional intensity of the various situations they may encounter. The interpreter serves as the voice for the patient, which in this setting can be emotionally devastating; for example, if the patient’s presenting issues are similar to unresolved issues in the interpreter. It is critical to provide interpreters with strategies for self-awareness and self-care – tools and techniques for ‘staying safe.’ The interpreter needs to be able to work in this setting, process information, and let it go. Anderson has herself completed training on how to be a life coach, which has provided many useful tools and techniques in this area. Anderson recommends – in the best of all scenarios – that interpreters work with a therapist or coach for a minimum of three months to increase self-awareness and psychological mindedness, thereby helping prepare them for interpreting in mental health settings.

Training and education of interpreters working in mental health settings should include an interpreter observation and supervision component. Anderson views the Dean/Pollard Observation Supervision approach as effective. She recommends that future training for work in this setting include opportunity for the interpreter participant to observe the therapist working with an actual patient, and then opportunity to debrief on those observations with experienced interpreters.

Interviewee: Dan Veltri

This video was developed by Dan Veltri and Kathleen Duffy for Treehouse Video ten years ago and is still being ordered for use in the field today. The video is 50 minutes long, comes with an instructor guide, and is typically ordered for use as a presentation tool in conjunction with a broader program or workshop being offered. It is most effective when used for education of already certified interpreters.

The video is organized around seven separate vignettes, each presented by professional actors. The vignettes portray various scenarios related to interpreting in mental health settings, each of which is designed to highlight a number of issues that might arise. Examples of situations include patient use of dysfluent language, leaving it up to the interpreter to signal the healthcare professional; hearing therapist overdependence on the interpreter, and leaning on the interpreter as if they are co-therapists with the clinician; therapists and providers who are ‘Deaf-naïve’, among others. The vignettes are purposely designed to be open-ended leaving them exposed to a wide range of interpretation and perspectives.

The interviewee has used the video in conjunction with a 1 ½ day workshop on the topic. In that forum, the video is played vignette-by-vignette. Each time the video is paused, instruction is provided based on the accompanying video instructor guide. Participants are organized into small breakout groups to discuss options and consequences. They share and compare strategies back in the larger group.

Challenges

The video is dated is several aspects. For example, it refers to technology in terms that are no longer relevant. While the video is ripe for a redo, it is not a priority of Treehouse Video Program. However, the company would be willing to provide the production expertise in a teaming arrangement with content experts from a training institute to update the video.

None of the vignettes demonstrate a certified Deaf interpreter working in the role of the interpreter. This is a major shortcoming of the video; it does not address the role of Deaf interpreters at all, which is a topic coming up more and more often, especially in the larger cities.

The video does not explore testing issues, for example, mental health status exams. These tests were designed and are most effective when used for hearing Caucasian patients. The tests are not as effective when used as assessment tools for Deaf mental health patients.

The video is not well advertised. Treehouse Video Program lists it as a product on their website, but they do not have a catalogue that is disseminated to the field, nor do they market it.

Treehouse Video Program does not have an established mechanism for customer feedback, so it is difficult to determine who is using the video, where, and whether or not it proved effective. Most feedback is anecdotal or word of mouth.

Recommended Components of Training and Education

Participants that seek education and training for interpreting in mental health settings should have prior interpreting education and experience, including work in this setting.

Knowledge of the DSM and a wide range of diagnoses and treatments encountered in mental health settings. Note: It is critical to strike the appropriate balance between imparting sufficient knowledge to be successful in this setting, and not creating the expectation that the interpreter be trained as a mental health professional.

Training and education should offer opportunities for the student to participate in the mental health provider/clinician meetings. This is an important aspect of the education in that it allows the interpreter to better understand the diagnosis and planned treatment of the patient. Again, there needs to be consideration when providing these forums that the expectation is not to prepare the interpreter to be an expert in mental healthcare.

Interpreters working in mental health settings should have access to ongoing supervision – supervision that goes beyond mentoring. They should have access to a sanctioned supervisory network (possibly by RID) that provides a forum for discussing situational options and consequences. There are many gray areas associated with working in this setting where the input, supervision and feedback of an interpreter with substantive experience in mental health environments is critical as a sounding board to the working practitioner.

The Dean-Pollard Observation/Supervision methodology is right on track. Education for interpreters working in these settings should begin with classroom learning, followed by the observation/supervision approach. Students should first observe the mental health clinician working with hearing patients, and then discuss and talk about what they observed. Then they should observe the clinician and an experienced interpreter working with a Deaf patient. Again, the observation period should be followed by the opportunity for discussion of options and consequences. Finally, the student should be provided the opportunity to work with the clinician – but still within the observation/supervision framework.

Education related to interpreting in mental health settings must also address the needs of the healthcare provider/clinician. The interpreter student should be prepared to provide research body resources and suggest materials to the clinician that is uncomfortable with ‘Deafness’. Today, many clinicians are not open to information that will assist them to best utilize the interpreter in the mental health setting. Work needs to be done by the field to create forums for building the relationship between the interpreter and clinician.

Education and training should address the need for standardized behavior on the part of interpreters. Today, across the range of interpreter settings, there are no norms the client, organization or consumer can expect with regard to interpreter performance, attitude and behavior. This is particularly critical in the emotional, highly charged mental health setting.

Recommendations for Program Delivery

Training should be tailored to the level of experience of the participant, and differ greatly with regard to interpreters that are already working in the setting, experienced interpreters that are planning on working in this setting, or novice interpreters entering the field.

Hands on classroom learning, with a heavy emphasis on observation, supervision and interactive discussion and debate, is the most effective approach. However, there may be aspects of the education that could be effectively delivered on-line or through distance learning channels for those experienced practitioners already working in mental health settings.

Mental Healthcare and Substance Abuse Interpreting

Interview Guide for Program Administrators

Introduction and Overview of NCIEC

I’ll introduce myself as a consultant that has been working with the Consortium over the past two years. I’ll also provide a brief overview of the NCIEC and its collaborative effort to establish effective practices in a number of key programmatic areas – including mental health interpreting. I’ll inform tell them about the NCIEC Mental Healthcare and Substance Abuse work team, and let them know the work team is leading this effort. I’ll briefly describe the work team’s charge and activities initiated to date. I’ll talk briefly about the draft domains and competencies. I’ll emphasize all of the work that has been accomplished to-date to develop the domains and competencies, and the work team’s effort to obtain the input and feedback of a wide range of experts in the field. I’ll also mention the work team’s ongoing efforts to involve and gather the input of consumers, providers and practitioners from across the country in all of their work.

Purpose of the Interview

I’ll broadly describe what we hope to gain out of the interview process, that is, to obtain input from content specialists like themselves that will assist the NCIEC work team to identify and establish resources to effectively prepare interpreters for work in this setting. I’ll inform them that the Consortium plans to develop a graduate certificate program in Mental Healthcare Interpreting – envisioned as a four-course program designed for on-line delivery in fall 2008. I’ll let them know the curriculum to be developed will be based on the essential elements of effective practice in mental healthcare interpreting, as agreed upon by consumers and experts alike, and will include the input of folks like themselves. I’ll also tell them that another intended outcome of the work team is a resource site on mental health interpreting, and let them know the Consortium will contact them again in the future to discuss potential links to their program through that site.

Information about the Program and the Context in which it Operates

I’ll ask the interviewee to broadly describe their program and to send us any documentation on it. I’ll probe to get them to describe program priorities and identify any challenges or opportunities facing their program, and I’ll ask them to describe the content of their program and the problem/issue it is designed to address. At this point, I’ll ask them on what basis they made decisions for establishing the particular program content. I’ll also ask if the interviewee can provide any demographic information about program participants so we can better understand the characteristics of the interpreters taking this type of education and where they are coming from. For example, are participants coming directly out of other educational programs; are they new graduates versus working interpreters; are they locally based or coming to the program from other parts of the country, etc. I’ll also ask how the prior experience of the participant is impacted by program content (for example, is the program geared for interpreters already working in this setting, or more toward those entering the field; has it had a more positive impact on one or another of these groups). It might also be interesting to understand how participants found out about the particular program, if that information is available.

Description of the Approach or Method Utilized by the Program

The objective will be to understand how the program is delivered, for example through classroom instruction, home study, on-line training, tutoring or mentoring, or through combination of any of the above. I’ll ask them on what basis they made their decisions for the particular approach or method they utilize to deliver their program. I’ll also ask them whether they have found some program delivery methods and processes to be more or less effective than others, and if they have any plans for changing and/or expanding the program and how it is delivered in the future, and the basis for those changes.

Description of Program Outcomes or Results

I’ll ask whether they collect any information that helps them understand the results and impact of their program on participants. Their description might include results based on anecdotes, observations, interviews, surveys, or any other means of collecting feedback from participants. I’ll ask them if they document any of this information, and if so, if they can share it with us. If it exists, this information would be helpful to the workteam as it evaluates the various programs and attempts to make judgments regarding content area or the effectiveness of one approach or method over another.

Open-ended Input

This is the critical part of the interview process. I’ll tell interviewees that we would like their thoughts regarding the spectrum of education and experience they think is necessary to prepare interpreters to work in this setting. I will encourage interviewees to think outside of the box and envision the best case scenario for education in this area. I’ll say something to the effect: “In the best of all worlds, without time or budget constraints, what education and experience do you believe an interpreter needs in order to be successful in mental health settings?” I’ll probe to investigate their opinions regarding not only with regard to content areas, but delivery options as well. I’ll also ask them to think about the best sequence of education and training, and to characterize their thoughts with regard to interpreters already working in this area, experienced interpreters that are planning on working in this setting, or novice interpreters entering the field.

Discussion of Next Steps

I’ll inform the interviewees that the work team plans on conducting additional information gathering activities, one of which would be to survey working interpreters that have completed education in this area, as well as interpreters that are currently working in this setting. I’ll explain that the objective of the survey will be to get input directly from interpreters regarding the type of education they have found most useful and would like more of in the future, as well as shortcomings and gaps in what is currently available in the field. I’ll ask them if they have conducted any surveys or assessments with the purpose of understanding needs in this area, and if so, whether they can share those instruments and results with us to help inform our own survey design and development. I’ll also ask the interviewees if they would be willing to provide feedback on our survey instrument once we develop it, and whether they would share their program participant lists and contact information so that we can include those individuals in our survey. I’ll also ask them if there are particular questions they would like us to ask in our survey that would help them better understand their own program. I’ll tell them they can provide us with suggested questions when they review our draft instrument.

Wrap-up

I’ll thank the interviewee for their time and make sure they know how to access the NCIEC website to stay informed on work team activities and the broader work of the Consortium. I’ll also ask each interviewee if they would be willing to work with the NCIEC in this area, and gauge whether they would be willing to participate in some manner in that effort in the future.

Resources Identified by Interviewees

Other Suggested Contacts

Bruce Downing

Associated with Treehouse Video Productions
Designed and delivered a course on mental health interpretingRecommended by Izabel Arocaha

Lisa Dignan, Director

New Mexico Mentoring Program
(800) 489-8539
Program recently completed development of a 16 week on-line mentoring curriculum for interpreters in the state working in mental health settings.Recommended by Arlyn Anderson

Diane Lolli, Director

Cambridge Medical and Mental Health Programslollid@comcast.net
Responsible for bringing together interpreter content experts and mental health providers to develop Cambridge program; has insight regarding what mental health providers think is most critical for interpreters to understand about mental health settings.Recommended by Izabel Arocha

Dr. Robert Basil, Program Director

Wright State University, Mental Health and Deafness Program
(937) 775-4300
Provides overall supervision and administration for the mental health program. They also post a lending library list which includes numerous resources for interpreting in mental health settings.WWW.wright.edu/sopp/mhdp

Darlene Zangara, CSD of Ohio

Zangara is a mental health counselor, who is Deaf. She has compiled numerous resources related to interpreting in mental health settings. She also runs a 2-3 day workshop annually, and has done one such workshop on the topic.Recommended by Greta Knigga

General Mental Health Information

American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision. Washington, DC: American Psychiatric Association.
*Bell, R. & Hall, R. (1977). The Mental Status Examination, ( 145-155). American Family Physician. Kansas City, MO: American Academy of Family Physicians.
Corina, D., Bellugi, U., & Reilly, J. (1999). Neuropsychological Studies of Linguistic and Affective Facial Expressions in Deaf Signers. Language and Speech 42 (2-3), 307-331.
Davison, G., Neale, J.M. & Kring, A. (2004). Abnormal Psychology. New York: John Wiley & Sons, Inc.
Goleman, D. (2005) Emotional Intelligence. New York: Bantam Books.
Kaplan, H., & Sadock, B. (1991). Comprehensive Glossary of Psychiatry and Psychology. Baltimore, MD: Williams and Wilkins.
Kaplan, H., & Sadock, B., (1991). Pocket Handbook of Clinical Psychiatry. Baltimore MD: Williams and Wilkins.
Miller, A. (1996). The Drama of the Gifted Child: The Search for the True Self. New York: Basic Books.
Rosdolsky, M. (2005). Translating Psychiatric Texts. The Alta Chronicle, 34, 35-39.
Tugg v. Towey. (1994, July 19). National Disability Law Reporter, 94-1063, 5.
Weinberg, G. (1996). The Heart of Psychotherapy: a Journey into the Mind and Office of the Therapist at Work. St. Martin’s Press.http://ps.psychiatryonline.org – Psychiatric Services, a journal of the American Psychiatric Association, was established in 1950, and is published monthly by the American Psychiatric Association for mental health professionals and others concerned with treatment and services for persons with mental illnesses and mental disabilities, in keeping with APA objectives to improve care and treatment, to promote research and professional education in psychiatric and related fields, and to advance the standards of all psychiatric services and facilities.www.aa.org – The official site of Alcoholics Anonymous; a good site to review the Twelve Steps and Twelve Traditions.www.dartmouth.edu/~admsep/resources/cinema.html – A summary of films that demonstrate pathologies, submitted by Ruth Levine, MD.www.healthyplace.com – A community site for mental health information, support and a place where others have shared their experiences.www.ilpvirginia.edu/index.html – This website is the home of the Institutes of Law, Psychiatry, and Public Policy. Look here for legal information relating to mental health.www.mentalhealth.samhaa.gov – This site gives good mental health links, dictionary, topics, resources as well as publications.www.mentalhelp.net – A good all-around mental health resource site.www.mentalhelp.org – This site is offered as a free public service by John M. Grohol, Psy.D.www.mmha.org.au – An interesting perspective on multicultural mental health, including interpreting services.www.psychcentral.com – A good all-around mental health resource site.www.rxlist.com – A good Internet research site for medications.www.schizophrenia.com – An interesting website with a variety of resources related to schizophrenia, including numerous blogs for examples of the personal experience of schizophrenia.www.rit.edu/SA/coun/SAISD – This is the alcohol and drug treatment site for Monroe County Substance Abuse Services for the Deaf. Good info site specific to deafness.www.whitehousedrugpolicy.gov – This site has good information for understanding how illegal drugs are used. Pictures and descriptions are given as well as good articles. For a 38 page document of “Street Terms: Drugs and the Drug Trade” that gives over 2,300 current drug-related street terms, contact the ONDCP Drug Policy Information Clearinghouse at 1-800-666-3332.

. Salem, OR: Sign Enhancers. 50 minutes. Voiced/Color/Signed. (Observe several realistic vignettes of challenging issues in the mental health setting. Learn from actual interpreters
in these dramatic portrayals with an analytical discussion of each situation. Informative guidebook included. Order from Harris Communications.)
Duffy, K. & Veltri, D. (1998). Interpreting in Therapy: Getting Out of the Way. VIEWS, 15 (4).
Edwards, M. & Patel, A. (2003). Telemedicine in the State of Maine: A Model for Growth Driven by Rural Needs. Telemedicine Journal and e-Health, 9, (1), 25-39.
Gerber, B. M. (1983). A Communication Minority: Deaf People and Mental Health Care. American Journal of Social Psychiatry 3, 50-57.
Gerber, B. M. (1979). Interpreter Effects with Deaf People. American Journal of Psychiatry, 136, 990.
Gibson, S. (2005, April). A First-Hand Account of Observation-Supervision Training. VIEWS, 22 (4).
*Green, L., Hawkins, A., Malcom, K., & Stewart, L. (2001). Psychotherapy with Deaf Clients: the Evolving Process of a Therapist/Interpreter Team. Vancouver Community Mental Health Services. Prepared for the Deaf, Hard of Hearing, and Deaf-Blind Well-Being Program.
Gunther, M. (1994). Counter-transference Issues in Staff Caregivers who Work to Rehabilitate Catastrophic-Injury Survivors. American Journal of Psychotherapy, 48, (2), 208-220.
*Guthman, D. The Gray Area: Ethics in Providing Clinical Services to Deaf and Hard of Hearing Individuals. Available on line at www.mncddeaf.org
*Hamerdinger, S., & Karlin, B. (2003). Therapy Using Interpreters: Questions on the Use of Interpreters in Therapeutic Settings for Monolingual Therapists. Journal of American Deafness and Rehabilitation Association. 36 (3). (An excellent article to share with clinicians who might be unfamiliar with working with a deaf consumer and interpreter in therapy.)
Harvey, M. (1984). Family Therapy with Deaf Persons: The Systemic Utilization of an Interpreter. Family Process, 23. 205-213. Also see www.michaelharvey-phd.com.
*Harvey, M. (1997). The Evolving Relationship Between Interpreter and Family Therapist. In M. McIntire, and S. Wilcox (Eds.), Journal of Interpretation. Silver Spring, MD: Registry of Interpreters for the Deaf, Inc.
Harvey, M. (1982). The Influence and Utilization of an Interpreter for Deaf Persons in Family Therapy. American Annals of the Deaf, 127 (7), 821-827.
Harvey, M. (1987). Guidelines for Interpreters in a Mental Health Setting: Applications from UCCD. San Francisco, CA: University of California
Harvey, M. (1987). Guidelines for Mental Health Professionals: Use of Interpreters for the Deaf from UCCD. San Francisco, CA: University of California.
*Harvey, M. (2001). The Hazards of Empathy: Vicarious Trauma of Interpreters for the Deaf. Journal of Interpretation. Registry of Interpreters for the Deaf, Inc.
* Harvey, M. (2001). Shielding Yourself from the Perils of Empathy. Journal of Interpretation, Registry of Interpreters for the Deaf, Inc.
Interpreting in the Mental Health Setting. Standard Practice Paper. http://rid.org Registry of Interpreters for the Deaf, Inc.
Interpreting within the Mental Health Setting: Interactive Interview, Consultation and Hearing

B. The interpreter will demonstrate knowledge of treatment protocols (policies, goals, dynamics, interventions, procedures) and the ability to work safely in the many settings of the modern continuum of care: emergency department, trauma situations (domestic violence, sexual abuse, etc.), crisis intervention, long term acute, and partial hospital care, residential, rehabilitation, intervention, long term, acute, and partial hospital care, residential rehabilitation, out patient (individual, group, adult, children), adult and child protective services, substance abuse\settings as well as knowledge of other therapeutic settings, (e.g.,admission and assessment procedures in secure and mandatory hold settings).

C. The interpreter will differentiate the purposes and goals of treatment plans and diagnostic assessments such as the Mental Status Exam, psychological testing and homicidal, suicidal, and self-harm assessments, etc.

D. The interpreter will demonstrate knowledge of the goals, procedures, and interventions of common therapeutic approaches used in mental health systems and how language and communication impact these different interventions, such as Cognitive Behavioral Therapy (CBT)/Dialectical Behavioral Therapy (DBT), EMDR (Eye Movement Desensitization Reprocessing), Family Systems Therapy, etc.

E. The interpreter will demonstrate knowledge of the objectives and procedures involved in the common approaches and intervening variables in substance abuse treatment such as detox, 12 step programs, relapse prevention, etc.

F. The interpreter will demonstrate understanding of the roles and functions of mental healthcare providers including psychiatrists, psychologists, psychiatric nurses, technicians, etc.

Domain II. Therapeutic Dynamics

A. The interpreter will demonstrate an understanding of common and complex therapeutic dynamics, especially 3rd party dimensions, and the interpreter’s potential impact and interference on the therapeutic process/relationship.

a. negotiate with the provider, strategies to minimize the interpreter’s presence in the therapeutic triad.
b. demonstrate the ability to manage these dynamics through
pre-/post-sessions, de-briefing, case conferences, multidisciplinary
supervision and mentoring.

2. Demonstrate an understanding of how linguistic choices can trigger reactions from the consumer as well as the therapist, affecting the participants’ reactions to each other.

B. The interpreter will demonstrate the ability to maintain professional boundaries, especially in situations and settings where boundaries are frequently challenged and to know what the special mental health-interpreting boundary challenges are.

1. Demonstrate ability to establish appropriate rapport and boundaries with consumer.
2. Articulate unique boundary challenges in the mental health settings (arising from consumer of mental health services, multiple roles, etc.) and how these differ from non-MHI assignments, decision making and consequence levels.
3. Understand notions of “confidential [trust] supervision and total silence” (what information can/should not be shared and with whom) and work with the provider to offer the consumer an understanding of what information will be shared within the team.

C. The interpreter will articulate how boundary challenges in mental health interpreting impact personal safety and mental well being and the need for the interpreter to develop personal care plans.

1. Demonstrate strategies for remaining physically safe in the various provider settings.

a. know the provider’s procedures and techniques of securing unstable patients, the extent of the interpreter’s responsibility for the consumer’s safety and how that would impact the safety of the interpreter.
b. follow Universal Precautions.
c. advocate for safe working conditions, (e.g., how to negotiate when asked to escort the consumer with no other staff present in an inpatient environment).

D. The interpreter will demonstrate ability to recognize, monitor and manage his/her own reactions to the content of the therapeutic session without imposing his/her reactions on either the provider or consumer.

1. Be aware of how to manage personal biases, sensitivities, “-isms,” and able to explore personal motivations.
2. Establish a formal structure in which to manage personal issues outside of interpretation settings.
3. Be able to discuss with the providers and colleagues the limitations of interpreting and why interpreted treatment is not equivalent to direct treatment.

Domain III. Interpreting Therapeutic Discourse

A. The interpreter will demonstrate understanding and decision-making ability concerning the use of consecutive and simultaneous interpretation.
B. The interpreter will demonstrate skills in providing linguistic and cultural equivalences to mirror the therapeutic interaction.

Domain IV. The Interpreter as Professional

A. The interpreter will demonstrate the ability to serve in a professional capacity on the multidisciplinary treatment team and understand other team member’s role with constant emphasis on maintaining the role of the interpreter.

1. Develop an identity and belief as a practice professional.
2. Understand what contributions, roles and boundaries each team member, including the interpreter, brings to the therapeutic process.
3. Understand and actively engage the professional interpreter role in the context of agency structure, dynamics, and public mental healthcare realities, trends, policies, etc.
4. Understand the similarities and differences between working as a staff interpreter and working as a freelance community interpreter.
5. Demonstrate respectful “people first” language (e.g., “people with schizophrenia”) at all times when communicating with providers, etc.
6. Team professionally with both deaf and hearing teams as appropriate.

B. The interpreter will anticipate areas of potential conflict at the interface of interpreting and mental health services regarding decision-making, problem-solving abilities, and resources in ethical codes of conduct, goals of providers, and triadic encounters.
C. The interpreter will demonstrate the ability to access a variety of problem-solving principles and resources to analyze and resolve impediments to effective interpreting, (e.g., Demand-Control Model, conflict resolution models, etc.).
D. The interpreter will demonstrate problem-solving strategies and resources.

1. Communicate with mental health providers about working effectively with interpreters.

a. analyze effectiveness of the interpretation, monitor understanding and effectively communicate that to provider.
b. demonstrate strategies for explaining distinctions in discourse styles, (e.g. role of narrative, abstract concepts,use of names).
c. able to discuss with the provider the compatibility of level of therapeutic interventions as evident in consumer discourse.

2. Develop team relationship/collaboration with providers.

a. provide information about language use patterns, abstract thinking, etc., (e.g., in connection with Mental Status Exam).
b. recognize and draw on available resources to effect communication, (e.g., group home staff, family members).
c. establish and share resources.

3. Appropriately advocate/consult around language and culture issues (culture broker) that could lead to misdiagnosis.

a. clarify as necessary to the provider assumptions/misconceptions around typical ASL behaviors (e.g. eye gaze, facial affect).
b. negotiate opportunities for interpreters to assess consumer language capabilities, word choice, language functioning while in the presence of the provider.
c. understand and be able to articulate to the provider, the impact of a deaf, deafblind, and hard of hearing person’s presence on group dynamics.
d. understand and be able to articulate to the provider the impact of interpreter’s presence on group dynamics.
e. analyze where responsibility lies in managing communication in group work and negotiate with provider
to achieve goals of the group with respect for deaf or deafblind cultures and rules of turn taking, role of storytelling in the culture.
f. negotiate challenges of working with multiple languages, consecutive interpreting, teamwork among interpreters (as in multicultural, multiethnic populations).

E. The interpreter will demonstrate a thorough knowledge of
relevant professional literature.

1. Know current mental health interpreting standards or certifications, and the Registry of Interpreters for the Deaf, Inc. Standard Practice Papers.
2. Be familiar with key literature, (e.g., history, epidemiology, ethics, evidence-based treatments, future trends, crosscultural issues, and people of color who are deaf, deafblind, and hard of hearing).

F. The interpreter will demonstrate commitment to ongoing education, self-care and life long learning.

1. Establish avenues for supervision, debriefing, mentorship, collegial support and consultation.
2. Develop resources and strategies for dealing with unsuccessful, unresolved cases, unaccomplished goals due to constraints placed on interpreter that prevent effective interpretation, detaching own value of self as professional from outcome when out of interpreter’s control.

G. The interpreter will understand interpreter’s role and responsibility in connection with applicable legal and ethical mandates and policies: HIPAA, duty-to-warn (Tarasoff), Child Protective Services, Adult Protective Services, legal privilege, etc., and is able to determine need to report and knows reporting procedures.

A Medical Interpreter: ASL/English is a credentialed professional with national certification, CDI or CSC or CI and CT or NIC Advanced or NIC Master (1), who facilitates communication between users of signed and spoken languages in health care settings throughout the life span. Qualifications include:

Bilingual fluency in English and ASL including the ability to produce and comprehend sociolinguistic variation.

Understanding of linguistic, social and cultural influences that impact health care interactions (e.g., specialized vocabulary, discourse styles, language register, dynamics of power and prestige between interlocutors, and triadic communication).

Adhering to the Registry of Interpreters for the Deaf and the National Association of the Deaf Code of Professional Conduct and familiarity with the NCIHC code of ethics.

Balancing the need for maintaining professional distance with empathy and flexibility.

Understanding underlying practices of various health care delivery systems and the role of self and others on the health care team (e.g., employing CDIs, Deaf Community Healthcare Workers [CHWs] and advocates when they can enhance the communication).

All of the following credentials are offered by the national Registry of Interpreters for the Deaf in the United States: CDI-Certified Deaf Interpreter, CSC-Comprehensive Skills Certificate, CI-Certificate of Interpretation, CT-Certificate of Transliteration, NIC-National Interpreter Certification.

Domain 1. Health Care Systems

The interpreter demonstrates knowledge of the health care context including differences between public and private health care systems and hospitals, various venues where medical care is provided, common diagnoses and treatments, institutional hierarchy, and roles and responsibilities of health care personnel.

The interpreter demonstrates knowledge of medical terms, procedures, and protocols of the health care system and specialized environments.

The interpreter discusses the role and function of the interpreter as part of the health care team in a professional manner.

The interpreter applies knowledge of health care systems and the rights and needs of Deaf, deaf-blind and hard of hearing people to affect positive and systemic change (e.g., health care literacy).

Domain 2. Multiculturalism and Diversity

The interpreter exhibits behaviors and practices that demonstrate respect for patients and healthcare providers from diverse backgrounds and with diverse beliefs, striving to provide interpreting services that respect the cultures, values and norms of the consumers involved. The interpreter demonstrates strategies for working with consumers for whom healthcare settings provoke increased anxiety.

The interpreter provides information to health care professionals regarding the importance of creating a visually accessible environment for Deaf, deaf-blind and hard of hearing people (e.g. communication boards, use of lights, avoid responding through an auditory intercom when patient presses call button).

The interpreter demonstrates strategies for working with Deaf people and health care professionals who have had prior negative experiences with access to health care (e.g., experiences of discrimination due to socioeconomic status or cultural beliefs).

The interpreter assesses and accommodates varied levels of language competency, knowing when to call in a specialist such as a CDI or Deaf Community Health Worker (CHW).

The interpreter demonstrates respect for consumers’ autonomy allowing consumers to make their own decisions.

The interpreter maintains awareness of changes in the communities in which s/he works, such as an infusion of immigrants, and is able to interpret in medical settings effectively for patients and providers with varying cultural and religious needs.

Domain 3. Self-Care

The interpreter recognizes issues in the work environment that may create distress within oneself and employs strategies for dealing with feelings (e.g., vicarious trauma).

Mental, emotional, social and spiritual wellness (e.g., journaling, exercising, seeking support from a trusted confidante or professional counselor).

The interpreter demonstrates awareness of personal safety practices in health care settings (e.g., stands behind a shield when x-rays are taken, wears a mask when a patient has an airborne disease, applies universal precautions).

The interpreter demonstrates physical and emotional stamina necessary for interpreting in health care settings, including how and when to call in a team member (e.g., procedures that last several hours such as births or procedures with intense smells).

Domain 4. Boundaries

The interpreter declines medical interpreting assignments that are beyond his/her capability, be it emotional, physical, or level of language competence.

The interpreter limits personal involvement with all parties during interpreting (e.g., not sharing or eliciting overly personal information in conversations with patients or health care providers).

The interpreter separates one’s own personal values and beliefs from those of other parties (e.g., interprets all reproductive choices to Deaf patient regardless of own beliefs).

The interpreter does not assume the right to make decisions for the patient and his/her treatment or healthcare plan and is aware of how the interpreter’s use of language can subtly change or influence decisions.

The interpreter works as part of an extended interpreting team sharing important information, language approaches, etc. with other interpreters serving the same patient, allowing for continuity of service.

The interpreter discloses or attempts to avoid potential conflicts of interest where professional boundaries may be compromised (e.g., does not interpret for a family member or close friends, may decline to interpret for a person’s performance appraisal at work if that person is a regular consumer in a health care setting).

The interpreter promotes patient autonomy (e.g., does not offer patients a ride home, or offer to pick up patients’ prescriptions).

The interpreter determines when it is appropriate to protect an individual from serious harm (e.g., intervenes on behalf of a patient with a life-threatening allergy, if the condition has been overlooked).

The interpreter consults with professional colleagues on matters of importance and concern (e.g., other interpreters, members of the health care team), and suggests ways to overcome communication or language challenges using a Deaf Interpreter, social worker, Community Health Worker (CHW) or patient advocate

The interpreter works as part of an interdisciplinary team to ensure effective communication.

The interpreter obtains relevant information prior to the specific interpreting assignment and has the skills to sufficiently research the background on various procedures and treatments to allow effective visual representation of the procedures.

The interpreter attempts to obtain appropriately relevant information prior to and during the specific interpreting assignment (e.g., reason for the appointment, reading brochures, studying charts on the walls).

The interpreter possesses a readiness plan for working in various situations such as with refugees and immigrants, for example, who may not have acquired ASL or English (e.g., uses models and pictures, knows when/how to get a CDI or Deaf CHW).

The interpreter maintains a sufficient amount of professional liability insurance.

Domain 6. Ethical and Professional Decision Making

The interpreter applies ethical principles in decision making, and understands the ramifications of decisions (e.g., when to accept or decline assignments).

The interpreter demonstrates awareness of the impact of demographics on decision-making (e.g., Deaf people may be known very well to the interpreter in a small town).

The interpreter demonstrates knowledge that the decision-making processes and the expectation to disclose and/or report certain information may be different between staff interpreters and freelance interpreters (e.g., staff interpreters may have more access to pertinent information and make different decisions than freelance interpreters).

The interpreter has advanced decision-making skills and knows when ethical dilemmas need to be resolved in collaboration with the patient and healthcare provider in order to lead to the best outcome for patient treatment and recovery.

The interpreter recognizes the need for patient privacy and exercises discretion about staying in the room or leaving (e.g., during medical procedures, private family conversations).

Domain 7. Language and Interpreting

The interpreter demonstrates ASL and English interpreting skills, linguistic competency, cultural knowledge and fluency in medical discourse in both English and ASL.

The interpreter is able to interpret both consecutively and simultaneously, understanding the ramifications of each format and demonstrating the knowledge and skills to move effectively between these formats during a single appointment or procedure (e.g. considers factors such as acute care needs and the potential for disrupting a participant’s train of thought when deciding whether or not to use consecutive interpreting).

The interpreter determines when an explanation of a specific interpreting process is required, and provides a rationale for its use (e.g. consecutive interpreting, simultaneous interpreting, or the use of a CDI).

The interpreter adapts the interpretation for age, gender, and culture (e.g., immigrants).

The interpreter adapts for individuals who are not proficient in ASL or English (e.g., uses a CDI when appropriate).

The interpreter communicates assertively in interactions with patients and service providers, in order to render an effective interpretation (e.g., if the health care provider is ready to leave the room before the interpretation is completed, the interpreter may intervene and ask the provider to wait for a moment in case there are questions).

The interpreter demonstrates skills in working as part of a team with CDIs and spoken language interpreters.

The interpreter is able to describe how language barriers can compromise access to health care for Deaf patients and health care providers.

The interpreter strives for accuracy when interpreting between all parties (e.g., knows when to seek clarification of the message).

The interpreter demonstrates strategies for interpreting in settings when the Deaf individual cannot see the interpreter (e.g., x-ray, eye exam, informs the providers that the resulting silence during the event does not constitute agreement).

The interpreter demonstrates strategies for interpreting in situations where the patient may become violent or is restrained (e.g., positioning self with ready access to the door).

The interpreter demonstrates strategies for use of first and third person pronouns and what to do when the health care provider uses the first and third person.

As possible, the interpreter notes on consent forms and legally binding forms that the materials have been interpreted.

Domain 8. Technology

The interpreter demonstrates knowledge of medical technology necessary to accurately interpret a procedure (e.g., use of classifiers for colonoscopy).

The interpreter is knowledgeable about video remote interpreting, pagers, video relay services and other forms of communication technology appropriate or necessary for the health care of Deaf, deaf-blind and hard of hearing individuals.

The interpreter uses information technology to broaden knowledge and research specific topics related to health care.

Domain 9. Research

The interpreter remains current by reading professional journal articles and incorporating new knowledge into practice and shares this knowledge with team members (e.g., other interpreters, mentees).

The interpreter critically evaluates research relevant to interpreting issues (e.g., uses appropriate analytical methods to make inferences linking research to practice).

The interpreter demonstrates awareness of current health care policies.

The interpreter maximizes the commonly available resources in the medical setting (grand rounds, lectures, observation of procedures) that can increase familiarity with the treatments and situations to be encountered.

The interpreter continually seeks available resources in the community (e.g., maintains and adds medical related literature and resources to a personal library).

The interpreter demonstrates awareness of liability issues related to ineffective interpretation with grave errors, including risk to the participants and risk to the interpreter.

Domain 11. Leadership

The interpreter may serve as a liaison between interpreting services and the health care system (e.g., agencies, regional and national interpreting organizations).

The interpreter may serve as a liaison between interpreter education programs and the health care system.

The interpreter provides mentoring and evaluation opportunities to staff and new interpreters in the health care setting (e.g., displays positive role modeling).

The interpreter promotes the establishment of policies and education that improve access for Deaf, deaf-blind and hard of hearing people to health care interpreting services.

The interpreter maintains positive and strong connections to the Deaf community.

The interpreter locates and uses community resources, both Deaf and non-deaf, when necessary to support their work (e.g., patient assistant, ombudsman, social worker, advocate).

Domain 12. Communication Advocacy

The interpreter demonstrates awareness of the political, sociological and cultural implications of advocacy (e.g., does not serve as an advocate when Deaf patients are capable of advocating on their own behalf).

The interpreter demonstrates knowledge of resources locally and nationally that can support a patient’s health care (e.g., awareness of group homes or other facilities and entities that can assist in patients’ health care).

The interpreter demonstrates understanding of health care culture and institutional hierarchy. When faced with patient care discrepancies, the interpreter reports the discrepancy to the appropriate personnel.

The interpreter encourages and supports self-advocacy when possible (e.g., may discuss self advocacy with the Deaf or hard of hearing patient).

The interpreter demonstrates standard and professional responses to common issues that arise regarding provider and patient rights, laws and procedures (e.g., may provide information to a patient about accessing grievance procedures).

The interpreter practices effective timing of providing communication advocacy (e.g., may provide information pre-, during, or post-patient/provider interactions, improve skills and enhance knowledge for how to work with interpreters).

The interpreter may work collaboratively with the Deaf community for advocacy efforts in health care settings (e.g., may present at Deaf meetings and events on health care advocacy issues).

The interpreter demonstrates knowledge of the RID/NAD Code of Professional Conduct and the implications of providing advocacy. The interpreter is also aware of the NCIHC code of ethics and its position on advocacy.

The interpreter provides health care providers with information about interpreting, and refers providers to Deaf, hard of hearing and deaf-blind people who can discuss Deaf culture, deafness, blindness and how the needs of individuals from these communities can be best met in the health care system.

The interpreter may provide family members of the Deaf patient with information about interpreting and may discuss the communication needs of the Deaf person and how to obtain access through interpretation.

The interpreter may provide Deaf, deaf-blind and hard of hearing communities with information about interpreting and how their needs can be best met in the health care system.

Domain 13. Professional Development

The interpreter stays current with practices in health care settings (e.g., immediately aware of universal precaution changes and updates, and may shadow health care personnel for educational purposes).

The interpreter develops and implements annual professional development plans (e.g., assesses gaps in knowledge addressing them with measurable goals).

The interpreter promotes the use of mentors from the Deaf, deaf-blind and hard of hearing communities (e.g., seeks out qualified mentors to assist in professional development activities).

The interpreter develops a portfolio for interpreting in healthcare, including credentials and professional experience (e.g., certifications, research, evidence of workshop attendance, independent studies).

Charge to the Task Force on Health Care Careers for the Deaf and Hard-of-Hearing Community

Our country has just completed a successful effort to broaden and reform our national health care system.

One of the major challenges now facing us in fulfilling the demands of this recently passed legislation is the critical shortage of health care specialists at all levels of training to care for the citizens of our nation.

This challenge coincides with another, much lesser known serious challenge; the limited opportunities for qualified deaf and hard-of-hearing individuals in this country to pursue careers in health care. Factors underlying this problem include:

Limited educational opportunities,

Widely held perceptions among the general population that health care careers are not appropriate for deaf and hard-of-hearing individuals, and

An insufficient number of deaf and hard-of-hearing health care professionals currently “at the table as insiders” to advocate for the needs and promise of people with hearing loss.

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Our Mission

Advancing ASL-English healthcare interpreters

The St. Catherine University CATIE Center Mental and Behavioral Health Interpreting project is funded by the U.S. Department of Education, Rehabilitation Services Administration, #H160D160003, from 2017-2021.

The contents of this website were developed under a grant from the Department of Education. However, these contents do not necessarily represent the policy of the Department of Education, and you should not assume endorsement by the Federal government.